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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: L l�� Tank i Size Product <br /> vl - <br /> Facility Address: ��'/f.5 ,if��.�-�-ya 2 <br /> /b 96c <br /> Telephone : 5;IR Z C3?—, 7 <br /> Person Filing ' <br /> Report -J 'I'l <br /> kiI 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. (No in Column 13 of the Inventory Reconciliation Sheet) <br /> ElInventory 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 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank E Amount <br /> 2. <br /> 71- <br /> 3. <br /> 4. <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 was due to <br /> a leak the incident shall be reported to S .J . L. H . D. Environmental Health <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within IS days of the end of each <br /> quarter. <br /> Quarter I - January --) March <br /> ,arter 2 - April --> June <br /> Quarter 3 - July --> Septemhcr <br /> Quarter 4 - October --) hrcrmher <br /> Send to: SAN JOAQU IN UAW, HEA1.11i DISTRICT <br /> 1601 H . Haze l I on , P -0 . It„x 1009 <br /> Stockton . CA 95201 400 - 6 /bl <br />