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.� O <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Q�v <br /> Tank f Size. Product <br /> Facilityuddresa: � I - <br /> 1. 71 - 'op5 <br /> Telephone : LCA `ms <br /> s ;,e_ <br /> Person Filing <br /> y�l� <br /> Report �2okn <br /> 0 1 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 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 /> was not due to an unauthorized (leak) releise. (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 p Tank / Amount <br /> 1. vI 0 S O Iiytaa T;;- P P'rtwwLw- ON���y 7�N SW✓ ({ZQ DY(,LL`4 F,Ly <br /> 2. 1 <br /> 3. <br /> 4. <br /> 5. <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 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 end of each <br /> quarter. <br /> Quarter 1 - January --) March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --) September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160L E. Hazelton , P .O . Rox 1009 <br /> Stockton , CA 95201 466-6761 <br /> IICT 40 10/ 86 <br />