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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name; / _ r;A, _ Tank t* <br /> Size Product <br /> FacilityAddceu; e� ,i <br /> Telephone : 1_ , ) :vi i-> •�, , <br /> Person Filing <br /> Report <br /> ED <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 Columa 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 DOC due to an unauthorized (leak) rel"se. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations chat exceeded the <br /> allowable limits. <br /> Oeste Tank f Amount <br /> 1. <br /> J. <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 whichexceeded allowable limits vas dun to <br /> Health leak the incident shall be reported to $ ,J . L.H. D , Environmenta <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 --) sepcemher <br /> Quarter 4 - October --) Occember <br /> Send co: SAN JOAQUIN 1,0CA1. HEAL11i UIS'l'f( (C1' <br /> 160E E. Ilazc• lt �ui , P .O . It<>x 200q <br />.:1' 40 LQ/HG SLockton , CA 95201 460-67b1 <br />