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INVENTORY RECONCILIATIONRECEIVU <br /> QUARTERLY SUMMARY REPORT FORM MAY 4 19,00/,4 31 <br /> FaciLity. Name: a ' <br /> Product, <br /> 4 <br /> Telephone : <br /> Person Filing <br /> Report y ° <br /> Ihereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the -allowable Limits for this <br /> quarter. (Ho in Colin l3of the Inventory Reconciliation Sheet) <br /> Q <br /> Inventory variatiaas exceeded the allo,.rabla. limits for this quarter. I <br /> hereby terrify under penalty of perjury that the source for the variation <br /> 'Was not due to an unauthorized (leak) releise. (Yes in Column 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 Amount , <br /> 4. <br /> 5. <br /> Additional dates/amnuats zh211 be continued on a separate sheet of <br /> _ paper and attached. <br /> If the source -of the variation which, exceeded al-lo+jable limits vas dun to <br /> a leak the incident shall, be reported to S ,J .L.H . D. Environmental l[ealth <br /> Within 24 hours and an unauthorized release report submitted. <br /> The quarterly sucmary report shall be Fubmitced within 15 days of <br /> quarter_ the end of each <br /> Quarter I j - January --> torch <br /> Q'sartcr 2 - April -,> June . <br /> Quarter 3 - July --> septemhcr <br /> Quarter 4 - October - -> Decraiber <br /> Send to: SAN JOAQUIN LOCAL 1JEALT11 DISTRICT <br /> 1601 H . H-1ZrIL(m , P .O . Is()x 1()()g <br /> bcockr-on , CA 95201 466-6781 <br /> T 110 10/86 <br />