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LENTORY RECONCILIATION <br /> QUARTERLY SUMMITRY REPORT FORM <br /> Facility Name l Cl Tank A Size Product <br /> to <br /> Facility Address: 0So eZ ) <br /> Telephone 0, - <br /> Person Filing \ <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 /> 2 . OF 3 <br /> 3• ENVIRONNIE y ;IAL HEALTH <br /> 4 . PERMFUSERVIOES <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---------->December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 B. Hazelton, P.O. Box 2009 <br /> Stockton, CA 95201 468-3420 <br /> Ell 23 019 10/86 <br />