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E is:/Y o -/V 6, <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Names _S'L/e/2i¢S �¢ :v'/�`St •/v/ <br /> /�/�I # �'Cd Tank t size. <br /> Product <br /> Facilit Address: <br /> Cf4 <br /> Telephone : ;21C l 9e2 I/ <br /> Person Filing <br /> Report J C#Al <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 /> 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 /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> i. ,;' <br /> 3. 1A <br /> 4. <br /> HEA <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation whichexceeded 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 --) Scptemher <br /> Quarter 4 - October --) (k'cc•mber <br /> Send to: SAN JOAQUIN LOCAL HEA1,TH DISTRICT <br /> 160L E . Haze 1 t o,n , P . O . f ox 2009 <br /> Stockton , CA 95201 466 -6781 <br /> 11(;1' 40 10/ 86 <br />