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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> l�aciLitr Name: C� �,� /� Tank # Sixe. Product <br /> lacilitr;Address: <br /> 77777 ,5�701 <br /> 777 <br /> Te I e p h o n e : �l_ -,�/ ' -G>'y 5�G- f' _' <br /> Person Filing <br /> Report <br /> E] 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 Coluam 13 of the Inventory Reconciliation Sheet) <br /> dInventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> vas 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. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper 2nd attached. <br /> If the source of the variation which. exceeded al'lowabLe 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 cnd of each <br /> quarter. <br /> Quarter I - January __> March �dlV� u f'I `� <br /> Quarter 2 - April --3 June �" 4 <br /> Quarter ] July -> September <br /> Quartc 4 - October --> December JAN 15 '138'; <br /> Send to: SAN JOAQUIN LOCAL HRAL1'1i U1S'1'K1CT ENViRONILEtNTAL HEALTH <br /> 160L E . k{aze 1 L o�tz , P .O . BOX 2009 C EWIT/SERVICES <br /> Stockton , CA 95201 466-6781 <br /> LILT 40 101136 <br />