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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Van bs' Bobs C.bnv - Tank # Size Product <br /> orclino "day K F <br /> Facility Address: Stockton, CA 95204 Z, <br /> A <br /> Telephone : A-7, <br /> Person Filing <br /> Report /f <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 # Amount <br /> 2. <br /> 3. ��81 <br /> 4. <br /> ENVIROMENTAL HEALTH <br /> 5. FERMIT/SERVICES <br /> Additional dates/amounts shall be continued on a separate sheet 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 --) March <br /> --Quarter 2 - April --) June <br /> Quarter 3 - July September <br /> Quarter 4 - October December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P .O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 <br />