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INVENTORY RECONCILIATIONp `- <br /> QUARTERLY SUMMARY REPORT FORM iUL 1 :51= <br /> Facility Name: �Q,pE/ 17oJ ��QM� Tank I Sim Product <br /> Faellity,Address: ��, ��) d <br /> �l)GCTOJ <br /> Telephone : 7i <br /> Person Filing <br /> Report <br /> IRII 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 /> ElInventory 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 Colum 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank I, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional daces/am»uots shall be continued an 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 /> carter - A rt -- June 1902, <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> Oecember <br /> Send to: SAN JOAQUIN LOCAL HEALTU D1STK ICT <br /> 1601 E . liaxell4m . P .O. HUX-2009 -.. <br /> Stockton . (.A 95201 466 -6761 <br /> UGT 40 I0/86 <br />