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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility flame: L fk Yr S7`e'" 1�rc d Tank f Size Product <br /> W,0- e-1 f 7 1440no ' <br /> Facility Address; j ` 2� -A "&r- <br /> 9 D <br /> Telephone : o g el 70 <br /> Person Filing II <br /> Report I Lkl .5 L-- a c `s - <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 Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for all variations that exceeded the <br /> allowable limits_ <br /> Date Tank t Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> parer ar.;! attached. <br /> If the source of the variation which. exceeded allowable limits was dui: 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 --) !larch <br /> Quarter 2 - April --> June �Tr� r�1;�� <br /> Quarter 3 - July --> September <br /> Quarter 4 - October -) December a� <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 L . IiaZt' 1 L()11 , 1' - 0 . '3():: 1()(79 ENVIRu.,v',EN IAL HEALTH <br /> Stockton , CA 95201 460-6781 FERMITAERVICES <br /> UMT 40 10/ 86 <br />