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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />F.cility !tame: <br />facility Add reaa <br />Telephone: <br />Person Filing <br />'1 <br />Report <br />Tank i Size Product <br />" c� <br />—C� 0 0 U <br />I 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 13of 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 variation <br />was not due to an unauthorized (leak) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />I <br />List date, tank /, and amount for all variations that exceeded the <br />allowable lis+its. <br />Date Tank f Amount <br />1. <br />2. <br />3. <br />4. <br />S. <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 alto-aable limits was due to <br />a leak the incident shall be reported to S . J . L . H . D . Environmental Lica l c h <br />within 24 hours and an unauthorized release report submitted. <br />Ike Quarterly summary report shall be rubmitted within 15 days of the end of each <br />Quarter. <br />Quarter I - January --) March <br />Q•Aartcr 2 - Apri l --) Jun(! <br />Quarter ] - July --> Scptcob�r <br />Q'iarter 4 - October --> December <br />Send to: SAN JOAQII IN 1.0(:AI. HEALI'li U I STI' I CT <br />1601 E. Hazelton. P.O. Ro x 2W)9 <br />SLockton. CA 95201 466-61b1 <br />T' 40 10/86 <br />n <br />