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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Ci`1'Jii?:a;ti^�;1'i+?'f;L 1�E!\LTH <br /> p�(7MI1 ! wEI�VIGES <br /> Facility Name: -T Tank f Size Product <br /> I10 o0o ank <br /> Facility Address: SM E RW )A � oo <br /> Lodi , 9=40 3 Qa t L fc <br /> Telephone : 001a� 461-1301 <br /> Person Filing <br /> Report ,SM1141 4t4- <br /> P<1 ereby certify under penalty of perjury that all inventory variations for <br /> above mentioned facility were within the allowable limits for this <br /> quarter. (No in Colum= 13 of the inventory Reconciliation Sheet) <br /> QInventory 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) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for all variations that exceeded the <br /> allowable lictits. <br /> Date Tank f Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Aaiditional dates/amouoc: shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation whichexceeded allowable limits was due to <br /> a leak the incident shall be reported to S .J . L.H . D . Environmental Health <br /> wt.chin 24 hours and an unauthorized release report submitted. <br /> The Quarterly summacy report shall be submitted within 15 days of the end of each <br /> Quarter. <br /> Quarter I - January --) March <br /> Q,iartcr 2 - April June <br /> -)�-Quarcer 3 - July --> Jcpccmh4-r (fw <br /> Quarter 4 - Octobcr --) I�:cember <br /> Send co: SAN JOAQU IN LOCAL. HEALTH U I;iTR ICI' <br /> 160L l. . Haze 1 t mi . P . 0 . 1iox 2009 <br /> Stockton , CA 95201 460 -6781 <br /> L1c;T 40 l 0/ 86 <br />