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r <br /> f. <br /> INVENTORY RECONCILIATION 6-vg <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name; A `(,� �� Tank / Size Product <br /> facility Address: f/� <br /> L>,- <br /> Telephone : U � 7 <br /> Person Filing y ' <br /> Report <br /> 1 hereby certify under pcualCy of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (No in Column 13of the inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable limits for tbis 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 Columon13 of the <br /> Invcotory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank E Amount <br /> I. <br /> 2. <br /> 3. <br /> 4. <br /> S. <br /> Additional dates/aMOuats shall be continued on a separate sheet of <br /> paper and acCached. <br /> If cite source of Che variation •+hich exceeded allowable limits Gas duc to <br /> a leak the incident shall be reported Co S .J . L. H . D. Environmental Ilealth <br /> WLchin 24 hours and an unauChorizcd release report submiCCcd. <br /> nic quarterly summary rcporC shall be Rubmicced within 15 days of Che end of each <br /> quar(cr. <br /> Quarcer I - January --) Harch <br /> Q,arter 2 - April --> Just: <br /> Q%Aarter ) - July --) September <br /> QA4rtcr 4 - October --) I Cvu3ber <br /> send to: SAN .JOAQU IN LOCAL HEAI.TI, <br /> 1601 F . Hazelton . P . 0 . 11„x Itlll'1 <br /> "Lockton , CA 9'5201 /,(,1, - 01b1 <br /> 111;"f 40 W/ 80 <br />