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INVENTORY RECONCILIATION /q?ov S / <br /> QUARTERLY SUMMARY REPORT FORM <br /> r <br /> Facility Name: Fr ,VLkcNCQr Tank i Site Product <br /> Faeiliey4ddrems: 11 C) I�hf«Cbe 1� ` U 'Gc �C>vi�117N <br /> -3 L ;CCS CCStL <br /> Telephone : <br /> Person Filing <br /> Report <br /> 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 /> E] 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 Tank I Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. excecded 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 7 - July --) septcmbrr <br /> Q,wrter 4 - October --) lhtccmber <br /> Send to: SAN JOAQUIN I.0CA1, HEAU'li D1STK1CT <br /> 160L E . I!azc• Ilim , P . O . Rox M09 <br /> Stockton , CA 95201 466 -67bl <br /> T 40 10/ HG <br />