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Facility Name: <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />fil��J U <br />Tank / duct <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 13 of the Inventory Reconciliation Sheet) <br />? .J <br />f4 -s:; <br />Facility Address: q-?i� <br />Telephone : <br />Person Filing <br />Report <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) 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 f Amount <br />1. <br />2. <br />3. <br />4. <br />5. <br />Additional dates/amounts shall be continued on a separate sheet of <br />paper snd 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 15 days of the end of each <br />Quarter. <br />Quarter I - January --) Harch <br />Quarter 2 - April --> June <br />Quarter 3 - July --) Septemher <br />Quarter 4 - October --) llccember <br />Send to: SAN JOAQU IN LOCAL HEALTH U I S'fh I CI' <br />1601 1-.*. Hazelton. P .O . Rox 2009 <br />Stockton, CA 95201 466-67b1 <br />Uc;T 40 10/86 <br />