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INVENTORY RECOtICILIANON <br />QUARTERLY SUMMARY REPORT FORM <br />Facility NZnc:N��c,_ <br />Fac. ity Address: <br />Telephone: <br />Person Filing <br />Report <br />QI hereby certify under penalty of perjury that all inventory variation <br />the Above mentioned facility were within the allowable limits for thea$ For <br />quarter. (Ko in Column l3 of the Inventory Reconciliation Sheet) <br />I®ventocy 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) release. (Yes i <br />Inventory Reconciliation Sheet) n Column 13 of the <br />Lint date, tank It and =mount for 211 variations that exceeded the <br />allowable liouits. <br />Date Tank I <br />Amount <br />`• <br />5. VAL <br />Additional datcs/amounts shall be continued on a separate sheet <br />Paper and attached. of <br />If the source of the variation which exceeded allowable limits was vue to <br />a leak the incident shall be reported to <br />Within 24 hours and an unauthorie•repv.H.D Environmental licaltI, <br />rcd r,•lcas <br />The quarterly summery repot[ shell b,r .ubmi <br />Q1,arCrr, tted within IS lays tit the end <br />of <br />Quarter I - Janunry --) Harch <br />¢carter 2 - April <br />Quarter l - July <br />Charter 4 - October <br />--> licccmber <br />Send to: SAN .JOAQEJIN LOCAI. 11LALTRR DISTRICT <br />1601 E. Hazelton, E1.0. Box 2009 <br />UCT 40 10/86 Stockton, CA 95201 466-6781 <br />