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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM ((�1anc�-onh�, <br /> Facility Name: `�`ficc_lcTo,� Cis„T;�� $C���,o� �; � Tank # Size J Product <br /> Facility Address : 11 E, P; _C) <br /> co, 9Sans <br /> Telephone: ef 4 06 q Coco c <br /> Person Filing ( �1LR,000 <br /> Report: . r- <br /> I hereby certify under penalty of perjury that all inventory variations <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 . lc - .) `1 - I C c%►tel E_ * 1 5 O Ceti <br /> 2 . 1C .. 3C` D E_ + 1q `3 �x l�anS <br /> 3 . <br /> 4 . <br /> 5 . <br /> Additional dates/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---------=>March <br /> Quarter 2 - April------------>June <br /> Quarter 3 - July------------->September Ls , <br /> Quarter 4 - October---------->December II ArR 2 U 1991 <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT ENVIRONMENTAL HEALTH <br /> 1601 E. Hazelton, P.O. Box 2009 PERMPSERVICES <br /> Stockton, CA 95201 468-3420 <br /> LII 23 019 10/86 <br />