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�► j <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />facility Name; <br />Facility Address: L/n7_=- E, <br />'r-Ap; / G <br />Telephone: !EoA _g7m7 ^— <br />Person Filing <br />Report'We— 'fZ1c <br />F,P <br />Tank % Size Product <br />Lf <br />0---,L hereby cectifY under penalty of perjury that all inventory variations for <br />the above mentioned facility were within the allowable limits for this <br />quarter. (Nc in Colum 110, the /nvegcocy Reccneliaticr. 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) release. (Yes in Column IJ of the <br />Inventory Reconciliation sheet) <br />List date, tack /, and amount for all variations that exceeded the <br />allowable limits. <br />Date <br />1. <br />2. <br />]. <br />4. <br />5. <br />Tack IT Amount <br />Additional dates/amounts *hall be continued on a scparatt 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„].1,.11, D. Environmental 11caltl. <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 />qurrtc.r, <br />Quarter I - January --) Hareh <br />Q.arter 2 - April --> June <br />Quarier 1 - July --) September <br />Q.a r to 4 - etcher --) Ik: a•mber <br />Send to: SAN .JOAQU IN LOCAL IIEALTH W S III I CT <br />I601 E. Uazellon, P.O. It.x 20119 <br />Stockton, CA 95201 466-61b1 <br />lll;'f /.() 111/)Sh <br />I <br />