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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMITRY REPORT FORM <br /> Facility Name: J & L MARKET Tank # <br /> Size Product <br /> Facility Address: 8115 S . E1 Dorado 1 2 000 as n ea <br /> Frenc amp , 2 10 , 00 as - He . <br /> Telephone: - 3 107 as - ial IrIll ted <br /> a <br /> Person Filing <br /> Report: <br /> I hereby certify under penalty of perjury that .all inventory variations <br /> Fx1 <br /> for the above mentioned facility were within the allowable limits for <br /> this quarter. (No in Column 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 varia- <br /> tion was not due to unauthorized ( leak) release. (Yes in Column 13 of <br /> the Inventory Reconciliation Sheet) . <br /> List date, tank # , 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 elates/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---------->Mar <br /> ch <br /> Quarter 2 - April---------- ��Ju <br /> Quarter 3 - July-------- <br /> ----->September <br /> Quarter 4 - October----------->December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 B. Hazelton, P.O. Box 2009 <br /> Stockton, CA 95201 468-3420 <br />-11 23 019 10/86 <br />