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INYENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> FaciLity. Hamc: '' .�• `� <br /> Tank # Sire• Product <br /> P:ciiity�llddress: �' <br /> Telephone : •� <br /> Person Filtng <br /> Report C, , kk , a►t)5__r)x 7 <br /> hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the-allowable liiaits for this <br /> quarter. (No in Column 13of the Inventory Reconciliation Sheet) <br /> ElInventory variations exceeded the allowable, limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> .was riot due to an unauthorized (leak) rete ae. (Yes in Colu=n 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I dk=unt , <br /> 4. <br /> sa 4,�' <br /> f p <br /> RA 7 <br /> zi, <br /> �ldditioaal daces/amothall <br /> uns sbe continued on ap rate .��`i+ec� <br /> paper and attached. s v/Q's <br /> If the source .of the variation which. exceeded at-lovable limits was due to <br /> a leak the incident shal1� be reported to S .J .L.1i . D. Environmcnta l Elea l ch <br /> WiChin 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted viChin 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) March <br /> Quarter Z - April --) June <br /> 'Quarter 3 - July �--> Septcmh4.r <br /> Q+,artfir 4 `i - Oct4bCr --> lhcembcr <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 1-. . l;ar.e 1 L atilt , P .O . Isaac 2009 <br /> SCockton , CA 95201 466-6781 <br /> T 40 10/86 <br /> f <br />