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0NVENTORY RECONCILIATION <br /> QunRTERLY SUMMARsy RF_PORT FORM <br /> Facility Name: <br /> /-eW Tank i Size <br /> roduct <br /> Facility Address: 0 D 00 <br /> J °Z 0 <br /> Tele03 <br /> paone : 5/ <br /> Person F in <br /> Report <br /> ❑ 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 Column 13of the loventory 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 as unauthorized (leak) release. (Yes in Column 13 of the <br /> Iaventory Reconciliation Sheet) <br /> List date, tank i, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank 0 Amount <br /> RErTly <br /> 3. <br /> ENVIRu v VILLA i AL HEK�I H <br /> 4' PERMIT/SERVICES <br /> Additional dates/amouats shall be continued on a separate sheet of <br /> paper and attached. <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. Environmental Ucalth <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly suamary report shall be submitted within 15 days of the and of each <br /> quarter_ <br /> Q"rccr I - January --) March <br /> Quarter 2 - April --> Junc <br /> Quarter 3 - July —> Scpccmber <br /> Quarter 4 - October --> December ' <br /> Send co: SAN JOAQUIN 1.0(:Al, HEALl•Ii UIS'l'RICT <br /> 1601 E. 11aze l ton . 11 .0 . Ilex 20(19 <br /> Stockton , CA 95201 466-676L <br /> UGT 1.0 10/86 <br />