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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Anheuser-Busch, Inc. Tank I Size <br /> Product <br /> Facility Address: 3932 Budweiser Court 1 <br /> 2 6 000 als. Gasol n <br /> toe tan, a ifornia 95205 <br /> Telephone : (209) 931-5661 <br /> Person Filing <br /> Report Ron Meyer <br /> [3X 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 13 of the Inventory Reconciliation Sheet) <br /> E] Inventory variations exceeded the allowable limits for this 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 Sank R Amount � Z 11 <br /> �J � �!Alfcafai. lJ <br /> ENVIRON' 1 AL HE <br /> FALTH <br /> 4. ERPoIIT <br /> 5. /SERVICES <br /> Additional daces/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 Fubmitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) March <br /> Quarter 2 - April --> J."e <br /> Quarter 3 - July --) September <br /> Quarter 4 - October --) (kcember <br /> Send to: SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> �. 160L E . HazelLqui . P .O . hox 2009 <br /> SLockLon . CA 95201 460 -6761 <br /> 7CT 40 10/86 <br />