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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: TQ Tank size <br /> Product <br /> racilit Address: <br /> Telephone : 5�, _ � I <br /> Person Filing <br /> Report <br /> Y hereby certify under penalty of perjury that all inventory variations for <br /> the above meationed facility were within the allowable limits for this <br /> quarter. (No in column 13 of the Inventory Reconciliation Sheet) <br /> QInventory variations exceeded the allowable limits for this quarter. t <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 /> l• Date lank f Amount � /=I � <br /> 2. ' <br /> 3. _ <br /> 4. _— —� ENVIROMENTAL HEALTH <br /> F ERMIT/SERVICES. <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 which. exceeded allowable limits vas 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 Rubmitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) Harch <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --) September <br /> f/ Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN C. CAL HEA1.11i DISTRICT <br /> 1601 E . Hazelton , P .O . Box 2009 <br /> Stockton , CA 95201 466-G7b1 <br /> LJ(;T 40 10/86 <br />