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`f INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Fici.lity Name: rQA/,Jk-k Exxod -4q^ Tank # Size Product <br /> E- <br /> 10.1000 <br /> Facility Address: !��QDzl�r. �2onfTlAGF��,��_ r 8- <br /> MAN,rECA . CA Q,;�311(r )_64000 <br /> Telephone : - <br /> Person Filing <br /> Report _A ,2o1J4o(A)EuL <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 allowable 'limits for',this quarter. I <br /> J 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 FAconciliation Sheet) <br /> List date, tank #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank # Amount <br /> 2. <br /> 3. _ 13s <br /> �f04 <br /> 5•. �� �a 15 <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 LOCAL HEALTH DISTINCT <br /> 1601 E. Hazelton , P .O . Box '2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 <br />