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SENTORY RECONCILIATION • <br /> QUARTERLY SUMMARY REPORT FORM <br /> JAN 3 M-0 <br /> raeilttY Mame: 6b �hctlw V?. a i cr,,, r,>> Al LTH <br /> Tank Slae Product i <br /> hcility;wddresas y799-3 Ccrrn,s � <br /> Telephone : 'nyh-O�Z6 rx� <br /> Person FilinF� - 00 <br /> Report <br /> LJ i hereby Certify under pesalty of <br /> the above w perjury that all inventory variations for <br /> mentioned Facility wore within the allowable limits for this <br /> quarter. (N-a is Column 13 gf the inventory Reconciliation Sheet) <br /> ❑ Inventory variations exceeded the allowable limits for this quarter. I <br /> beraby certify under penalty of perjury that the source for the variation <br /> was not due to as unauthorised (leak) releise. (Yes in Column 13 of the <br /> Inventory Recooeiliatioa Sheet) <br /> List date, task and amount <br /> allowable limits.. for all variations that exceeded the <br /> Date Tank Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additioaal dates/amounts shall be continued oo a separate sheet of <br /> Paper and attached. <br /> If the source of the variation which. exceeded allowable limits was due to <br /> • leak the incident shall be reported to $ ,J .L.H . D . Environmental Health <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter 1 - January --) March <br /> Quarter 2 - April --) June <br /> Quarter 3 - July --> September <br /> Quarter 4 - october r-> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH UIS'I'KICI' <br /> 1601 E. Hazelton , P . O . I1()x 2009 <br /> GT 40 10/KG Stockton , CA 95201 466-6761 <br />