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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM EN'VIRDAIiENTAL HEALTH <br /> f _/� FERn411-/SERVICES <br /> Facility flame: �a" � � rc°� !f -6 0 Tank # Size Product <br /> �c+ My7 d G'�O � r�f-i-,F <br /> Facility Address: (p/ � ol, 7 �t- -`,^ C C U ' <br /> Telephone <br /> Person Fili <br /> Report rum <br /> I 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 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 variation <br /> was not due to an unauthorized (_leak) release. (Yes in Colin 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 /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate skeet of <br /> paper and attached. <br /> If the source of the variation which exceeded allowable limits was due to <br /> a leak the incident shall be reported to S .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 I - .January _-7 March <br /> Qjarter 2 - April --> June <br /> Quarter 3 July --> September <br /> Quartdr 4 - October <br /> Send to: SAN JOAQUIN LOCAL HFALTE DISTkICT <br /> 1601 E . Iiaze 1 (-oil , P . 0 . B0% 1(1(19 <br /> Stockton , CA { 5201 466 -67 51 <br /> U(,T 40 10/86 <br />