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INYENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Names <br /> Tank I Sizc <br /> Product <br /> Facility <br /> ;Address: <br /> Telephone : � . <br /> Person Filing <br /> Report / /%�•/ >r / <r��jY <br /> i <br /> Qi 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. (Ho in Column 130E 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 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 Chat exceeded the <br /> Allowable linica. <br /> Date_ Tank / Amount <br /> 1. <br /> 4. <br /> S. <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 vas due to <br /> a leak the incident shall be reported to S .J .L.H. D. Environmental HealCh <br /> Within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within <br /> quarter. 15 days of the end of each <br /> Quarter I - January --) March <br /> Quarter 2 - April --) June <br /> Quarter J - July --> September <br /> Quarter 4 - October --> Ikcember <br /> Send to: SAN JOAQUIN LOCAL HEALTH U1S'1'k1CT <br /> 1601 l:. Ilazt• I ( cin , P .O . lio c 2()09 <br /> CT 40 10/86 SIOCkron , CA 95201 466-67b1 I <br />