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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Suoaib>u 6uf- lJ-f Il ' ri Tank f Size Product <br /> Facility Address: / 767 C m__= S-f- o <br /> Telephone : _fzv v) 9�L tr3-y <br /> Person Filing <br /> Report <br /> ® I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility -ere within the allowable limits for this <br /> quarter. (Mo in Column I3of 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) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank i, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> 1• 7�/�k5 _ 7--i7 + 31.0 <br /> 2. $ ✓r T-77 — 32.y <br /> 3- 8,J(./8-9 T-17 — YS,s <br /> 4. &l/yAl T-17 t,28-4- <br /> 5• 8,//5/fry T-17 1-29_ G <br /> Additional daces/amounts 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 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 /> Quarter I - January March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July —> September <br /> Quarter 4 - October —> December <br /> Send Co- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton, P .O. Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 <br />