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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name; I / <br /> ail Tank t Size Product <br /> Facility,'Addresa; / "�" t' <br /> Telephone : c <br /> Person Filing <br /> Report , } <br /> 1 hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (No in Column 13of the inventory Reconciliation Sheet) <br /> ❑ Inventory variations exceeded the allovable. limitz for this quarter. I <br /> hereby certify under Penalty of perjury that the source for the variation <br /> was nor due to an unauthorized (leak) rele'a'se. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank /, and amount for all varia <br /> Allowable limits. tions that exceeded the <br /> �q+ s @� <br /> Date Tank Amount . R i _EI 'VE <br /> 1_ �s� [[[+++rrr AA R■T }� <br /> 2, JAN 0 3 1992 <br /> 3. ENVIRONMENTAL HEALTH <br /> 4. PERMIT/SERVICES <br /> s. <br /> Additional _dates/amounts shall be continued on a separate sheet of <br /> paper and aCtachcd. <br /> if the source .of the variation which. exceeded al-lovable limits was due to <br /> A leak the incident shallbe reported to <br /> within 24 hours and an unauthorizEnviro�ntal Ilea ICh <br /> ed cclease report s$ ,J ,L.H . D.. <br /> The quarterly summary report shall be submitted within I$ days of the end of each <br /> quarter. <br /> Quarter I - January --) March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> jeptcmhcr <br /> g 4 i arter - October --) fh:ccmber <br /> Send co: SAN JOAQUIN LOCAL HEALTH UISTRIC-1• <br /> 1G0L V . I!a%Cllnl , !' .0 . Itox 20()9 <br /> 4U l0/HG Slockron . CA 95'101 466-6781 <br /> �' <br />