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r <br /> INVENTORY RE'CONCILIATIOh* <br /> QUARTERLY SUMMARY REPORT FORM(-_k, <br /> Facility Name e- <br /> Tank # Size Product <br /> Facility Address: <br /> 2 <br /> Telephone: $'3 <br /> Person Filing <br /> Report: . Tom T , <br /> ❑ I hereby certify under penalty of perjury that .all inventory variations <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. I <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 . <br /> 2 . <br /> 3 . /!hz 3 <br /> moi;y <br /> 4 . _ <br /> 5. c/�b�t3 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 /> uarter 4 - October---------->December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton, P.O. Box 2009 <br /> Stockton, CA 95201 468-3420 <br /> EH 23 019 10/86 <br />