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INATORY RECONCILIATIOtt <br /> x <br /> QUARTERLY -SUMMARY REPORT FORM <br /> Facility Hame: vT �t/C' 7� Tank I Size. Product+ <br /> i <br /> Fit cility 4'Addresa: G% G�/+� /�rGr.�l_ �'• U �' <br /> Telephone :/, <br /> Person Filing <br /> Report <br /> El' X 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 /> Xuventory variations exceeded the aliovable limits for this quarter. ' I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to as unauthorized (leak) release, (yes in Column 13 of the <br /> Iaveatory Reconciliation Sheet) <br /> List date, tank #, sad amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank fAmounc J <br /> ..� 4N <br /> 2. <br /> 3. <br /> 4. <br /> S. q <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> s <br /> i <br /> Lf the source of the variation which. exceeded allowable limits was due to <br /> 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 Rubmitted within 15 days of the end of each <br /> quarter_ <br /> Quarter I - Jaauary --) March <br /> Q•la=ter 2 - Aoril --3 .lune <br /> Qiarter 3 - July --) Sept cmhcr <br /> Q,�Uartcr 4 - October --)-December floe <br /> Scnd to: SAN JOAQUIN LOCAL HEALTH 1)1STH ICT <br /> 1601 E. lfa elLoli , P .O . Box 2009 <br /> Stockton , CA 95201 466 -6761 <br /> T 40 10/ 86 <br />