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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />RECEIVED <br />1991 <br />ENVIRONMENTAL HEALTH <br />X7,'1111 ,_ `1111',1 c <br />Facility Name: <br />Facility Address: <br />Telephone: z _g -74 7 <br />Person Filing <br />Report <br />TankaT Size Product <br />F <br />I hereby certify underenalt f <br />P y operjury 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, tack i, 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 />S. <br />Additional dates/amouots shall be continued on a separate sheet of <br />paper ind 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 ..I . L. H. D. Envi ronmenta l 11ca l t h <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 1 - January --> Harc1i <br />QQaarter 1 - April --> June <br />Quarter ) - July --) Septemher <br />Q`Aartcr - ctober --> Ikce•ml)er <br />Send to: SAN JOAQLJ IN LOCAL HEALTH DISTRICT <br />1601 I:. Haze 1 l e►n , P .O . Itiix 111110 <br />Stockton, CA e15201 466-61b1 <br />tl(;,I. 4O IO/>i() <br />