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INVENTORY RECONCILIATION <br /> '? JAN 05 198pu <br /> QUARTERLY SUMMARY REPORT FORM <br /> ENVIROMENTAL HEALTH <br /> Facility Name: Anheuser-Busch, Inc. Tank R gLze Product <br /> 1 <br /> PaeiliiCy Address: 3932 Budweiser Court2 000 aleGasoline <br /> toe tan, a iiornia 95205 <br /> Telephone : (209) 931-5661 <br /> Person Filing <br /> Report Ron Meyer <br /> ©X I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable Limits for this <br /> quarter. (No in Column 13of the Inventory Reconciliation Sheet) <br /> ElInventory variations exceeded the allowable limits for thin quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank /, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank it Amount <br /> \ 1_ <br /> 2. <br /> 3. <br /> 4. <br /> S. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. exceeded allowable limits was due to <br /> a leak the incident shall be reported to S ,J .L.H . D . Environmental Health <br /> within 24 hours and an unauthorized release report submitted. <br /> The Quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --) September <br /> Quarter 4 - October --> Occcmber <br /> end to: SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 1601 E. Haze 1 L.m , P . O . 11ox 2009 <br /> Stockton , (.A 95201 460 -67b1 <br /> 1' 40 10180 <br />