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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> FaciLity Name; f , - f��,� ,�' Tank Size. Product <br /> Facility,Address; -cG% / 5 fJ��r /(" ; <br /> Te I e p h o n e <br /> Person Filing <br /> Report <br /> ❑ 1 hereby certify under penalty of perjury that all inventory variations fo <br /> the above mentioned facility were within the allowable limits for this <br /> carter. <br /> q (Ho to Columo [3 of the Inventory Reconciliation Sheet) ip#'•' , <br /> r��� <br /> ✓ Inventory variations exceeded the allowable limits for this guar er. <br /> hereby certify under penalty of perjury that the source for the variation ;�r�P LIA <br /> vas not due to an unauthorized (leak) relexae. (Yes in Column 13 of [he4\y, ` \--fl4 <br /> Inventory Reconciliation Sheet) E� "CE5l <br /> List date, tack I, and amount for all variations that exceeded the <br /> allowable liinits. <br /> Date Tank 0 Amount <br /> 7-7- <br /> 3. 11-1Z;1161& <br /> 02 <br /> 4. <br /> Additional dates/amouets shall be continued on a separate sheet of <br /> paper and attached. <br /> Lf 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 ,p, 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 /> ar[er 1 anuar --) March <br /> Quarter 2 - April --) June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEAL11I UIS'1'k1CT <br /> 1601 E. liaze 1 Loll , P .O . Box 2009 <br /> Stockton , CA 95201 466-6761 <br /> L1CT 40 ta/86 <br />