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4W <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Tank # size product <br /> Facility Address: 6767 C-_ � <br /> Telephone : <br /> Person Filing, C�� <br /> Report <br /> ElI 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. (Ho in Column 13 of 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 /> vas not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits_ <br /> Date Tank # Amount <br /> 2. t_� - <br /> 3. } Y 7 -17 + 63, f <br /> 4. 2- .2 S 111 <br /> Additional dates/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 suumiary 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 to: SAN .:OAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E , Hazelton, P .O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/ 86 <br /> 1 <br />