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� w <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name : �i�i• Tank I Size Product <br /> . <br /> Facility Address: `, ,�� , _ <br /> Li l' Gi 9 z 3 2�c90 L <br /> Telephone: &_ <br /> Person riling <br /> Report: //u%.s.•�'- <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 /> �j 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 . <br /> 2 . <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 ]. - January---------->March <br /> Quarter 2 - April------------>June <br /> Quarter 3 - July------------->September <br /> _ Quarter 4 - October---------->December /�fT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT '` ' ,4 <br /> Send to: y` ^ <br /> _z,. <br /> 1601 E. Hazelton, P.O. Box 2009 FEB 61 <br /> Stockton, CA 95201 468-3420 ►1ligi_ HEAL H' <br /> LII 23 019 10/86 <br />