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i► j L; ; <br /> INVENTORY RECONCILIATIONV <br /> QUARTERLY SUMMARY REPORT FORM '' 1 <br /> i E ALTI I <br /> FacilityName: 2An/Ks n�CIF STo�tboD mAv-T y Tank t `Size product <br /> Facility Address: N&D <br /> Telephone : t1- 575 <br /> Person fling <br /> Report 1 n X 00 n L" ),)c <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 13 of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowablelimits for this quarter. I <br /> 'T 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 f Amount <br /> 1. lD-1-45 en <br /> _. Ili- (o -P� .�_ 913 <br /> 3. /o- f4-R R <br /> 4. 10-11-88 � <br /> 5.. n-l�f-f38 _ �r1G <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 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 LOCA1, HEALTH DISTRICT <br /> 1601 E . Hazelton , P .O . Box 2009 <br /> Stockton , CA 95201. 466-6781 <br /> UGT 40 10/86 <br />