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lh•NTORY RECONCILIATION <br /> L QUARTERLY SUMMARY REPORT FORK Y <br /> Facility Name: `{ o�-r— Df �7TJ N.l�Onf' Tank f Siu. " <br /> Pr du<t <br /> [xcility-4ddress: .a& i w. (•Q�q_ Ste: ) nj' d t .. <br /> Telephone :,�oQ 9yG- ats G ale <br /> Person FilinP <br /> Report <br /> `a I hereby certify under penalty of perjury that 811 inventory variations for <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (No in Coluao I7of 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) relelade (yes in Colusar 17 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date <br /> ���� � Tank f Amount <br /> a� <br /> 7. <br /> 4. <br /> 5. <br /> Additional daces/amowacs shall be continued an a separate sheet of <br /> Paper and a[tached. <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. EaviraamenCal 11calth <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 1 - January --> Hareh <br /> Qin rcer 2 - <br /> Wartec 7 - July —7 SepCemher <br /> ".r.er 4 - uctobe. —7 uecrmue. <br /> Send Co: SAN JOAQUIN LOCAL HEALTH ULS'rH1CT <br /> 1601 E. Hazcltun , P .O. Box 2009 <br /> Stockton . CA 95201 466-6781 <br /> :'r 40 10/86 <br />