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4 <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Nase; Tank f Sire <br /> C-) roduct <br /> Facility Address; q4 �, �'�' <br /> z � E _ <br /> . �'f'cr� n <br /> Telephone : ✓ . r <br /> Person F.f •. <br /> Report _� v <br /> L 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 I3 of the Inventory Reconciliation Sheet) <br /> ❑ Lnventocy 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 unauthorised (leek) release. (Yes in co h 13 of the <br /> r Inventory Reconciliation Sheet) <br /> List date, tank /, and aa.ount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank / Amount <br /> APR <br /> 3. i <br /> 4 <br /> ENVIRUM&VTAL HLH FERMIT <br /> RVIN <br /> S /SECESLT <br /> Additional daces/amouocs chill be continued oa a separate sheet of <br /> paper and actachcd. <br /> If the source of the variation which exceeded allo..able limits w s du(: co <br /> A leak the cncidcnc shall be reported toS .J . [_ . H . D . Environmental health <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly susan..ary report shall be aubmit.[ed vi[hin 15 days of the end of each <br /> quarter. <br /> Quarter I - Janu.ry --) n..rch <br /> Quarter 2 - April --> Jun.. <br /> Quarter 3 - July __> Jc ptcmhcr <br /> Quarter 4 - OCCObcr --) Occembcr <br /> Send to: SAN JOAQU [N LOCAL HEALI H D I S IR I CI <br /> 1601 E . I!:Izt• I ( rui , 1' . 0 . Ito.x )()()'1 <br /> 40 10/H0 Stockton , CA '15201 460 - 0 )bI <br /> T <br />