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A/ INVENTORY RECONCILIATION <br /> J6 1.4 <br /> QUARTERLY SUMMARY REPORT FOMVIR <br /> Facility Name: X I <br /> Tank "Prbduct <br /> Facility Address : '2"' <br /> Telephone: . 57 <br /> Person Filinq <br /> Report : , <br /> -------------------- <br /> I hereby certify under penalty of perjury that -a-11 inventory variations <br /> for the above mentioned facility were within the allowable limits fr <br /> this quarter. (No in Column 13 of the Inventory Reconciliation Sheeot. ) <br /> Inventory variations exceeded the allowable limits for this quarter. I <br /> ❑ hereby certify under penalty of perjury that the source for the varia- <br /> tion was not due to unauthorized ( leak) release. (Yes in Column 13 of <br /> the Inventory Reconciliation Sheet) . <br /> List date, tank It , and amount for all variations that exceeded <br /> the allowable limits . <br /> Date Tank # Amount <br /> 1 . <br /> 2 . <br /> 3 . <br /> 4 . <br /> 5 . <br /> Additional dates/amounts shall be continued on a separate sheet <br /> paper and attached. <br /> If the source of the variation which exceeded allowable limits was <br /> due to a leak, the incident shall be reported to San Joaquin Local <br /> Health District; Environmental Health Division, within twenty-four <br /> ( 24 ) hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within fifteen (15 ) days <br /> of the end of each quarter. <br /> Quarter 1 - January---------->March A?r. / 5 <br /> Quarter r t e_ry'_)_ A p r i 1------------>June 15 <br /> Quarter 3 - July------------->September ncf 15 <br /> Quarter 4 - October---------->December <br /> 1 IS <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 U. Hazelton, P.O. Box 2009 <br /> Stockton, CA 95201 468-3420 <br /> EH 23 019 10/86 <br />