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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: 77 _ ierCy.J Tank / Size Product <br /> Facility,Address: C �,,L� �} <br /> r <br /> Telephone : <br /> Person Filing <br /> Report / u1 <br /> ® 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 /> 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 Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations chat exceeded the <br /> allowable limits. <br /> ;M <br /> Date Tank f Amount n '...,,J4,e'.::; ., ` <br /> MVV// <br /> 2. <br /> 3. <br /> ENVIRGI NERV C�STH <br /> 4. FERM.i7/5 <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> if the source of the variation vhich. ezceeded allowable !;=its was due to <br /> ■ 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 suomary 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 - u y --) Septcmher <br /> Quarter 4 - October --) D---comber <br /> Send to: SAN JOAQUIN LOCAL HEAL1'li DIS'1'HLC'!' <br /> 1601 E. . Haze 11 (III , 1' .0 . Box 2009 <br /> Stockton , CA 95201 466-67bl <br /> Uc:T 40 10/ 86 <br />