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r '1 0 1* /,�/ 7 <br />a—INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Facility Address: 2 �;-I� <br />Telephone: yy <br />Person Filin�7� <br />Report:, <br />LULU13 SS4-/ELL- Tank <br />LUV N'V <br />Size Product <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. - 2 % <br />2. <br />3. e Y <br />4. s IV?Z, 7 <br />5. 7 �� 7 <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 <br />Quarter 4 - October ---------- >December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 468-3420 <br />EH 23 019 10/86 <br />