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MVENTORY RECONCILIATION• <br /> nn QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: V J n - Tank I Size Product <br /> Ii✓ � L <br /> Facility Address : L) , , r1\tilrc 0-0 <br /> Telephone: o'06� —pa 10 <br /> Person Piling _ <br /> Report : <br /> I hereby certify under penalty of perjury that all inventory variation: <br /> ❑ for the above mentioned facility were within the allowable limits for <br /> this quarter. (No in Column 13 of the Inventory Reconciliation Sheet. <br /> Inventory variations exceeded the allowable limits for this quarter. <br /> hereby certify under penalty of perjury that the source for the varia- <br /> tion was not due to unauthorized ( leak) release. ( Yes in Column 13 of <br /> the Inventory Reconciliation Sheet) . <br /> List date, tank # , and amount for all variations that exceeded <br /> the allowable limits. <br /> Date Tank # Amount <br /> 1. (Z- �- qC�' kf �'� ������•�, <br /> 2. <br /> 3 . <br /> 4 . <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet <br /> paper and attached. <br /> if the source of the variation which exceeded allowable limits was <br /> due to a leak, the incident shall be reported to San Joaquin Local <br /> Health District; Environmental Health Division, within twenty-four <br /> ( 24 ) hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within fifteen ( 15 ) days <br /> of the end of each quarter. <br /> Quarter 1 - January---------->March <br /> Quarter 2 - April------------>June <br /> Quarter 3 - July------------->September <br /> Quarter 4 - October---------->Decemuer__ - <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton, P.O. Box 2009 <br /> Stockton, CA 95201 468-3420 <br /> Ell 23 019 10/86 <br />