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• <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name : EftlIA&(/ <br /> Tank # Size Pro uct <br /> Facility Address : s3 /l� <br /> Telephone • �A 4O0 <br /> Person ,ew � <br /> Report :— QJ'�/ <br /> [ ] I Hereby certify under penalty of perjury that all inventory <br /> variations for the above mentioned facility were within the allowable <br /> limits for this quarter. (No in Column 13 of the Inventory <br /> Reconciliation Sheet ) . <br /> [X] Inventory variations exceeded the allowable limits for this quarter. <br /> I hereby certify under penalty of perjury that the source for the <br /> variation was not due to an unauthorized ( leak) release . (Yes in <br /> Column 13 of the Inventory Reconciliation Sheet ) . <br /> List date, tank # , and amount for all variations that exceeded the <br /> allowable limits . <br /> e,p <br /> Date Tank # Amount <br /> — n � ��1 t� o <br /> I . -454v-- i <br /> � <br /> 2 . pre <br /> 3 . <br /> 4 . E <PERM(nl SF' VICE LCIi <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 exceeded allowable limits was due <br /> to a leak the incident shall be reported to S .J.L. H.D. Environmental <br /> Health within 24 -hours and an unauthorized release report submitted . <br /> The quarterly summary report shall be submitted within 15 days of the <br /> end of each 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 /> 1601 E. Hazelton, P. 0. Box 2009 <br /> Stockton, CA 95201 466-6781 <br /> T 40 10/86 <br />