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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: -2 ,i Ez <br />lracility Address: ZJ<r/ -_- /,a"/ �J-- <br />Telephone: 77777-77 <br />Person Filing ' <br />Report LAC��,-,,D, � -' <br />Tank i Size Product <br />1 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 loventory 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) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />I <br />List date, tank f, and amount for all variations that exceeded the <br />allowable limits. <br />7inlDate Tank a>E Mount <br />2. MAY 1 1989 <br />3. <br />4. LNVIRCNMI;NcT�AL. HEA' -'i-, I <br />'�t2P1�rT �.S(.i 4V1 v\i. <br />S. <br />AdditiocaL dates/amounts shall be continued on a separate sheet of <br />paper .and 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.J.L.H.D. Environmental Health <br />within 24 hours and an unauthorized release report submitted. <br />i-hc Quarterly summary report shall be submitted within 15 days of the end of each <br />Quarter. <br />Quarter 1 - January --) March <br />iartcr - pri-C--- -_�- Ju���• <br />Quarter I - July --> leptemh4!r <br />Q%sarter 4 - October --) Ovcc•mber <br />Send to: SAN JOAQU IN I.0CA1, HEA1.11i U I STH ICT <br />1601 K. Ilaze I t inn . P.O. Itc�x 2009 <br />Siockton, CA 95201 466-67b1 <br />1' 40 10/86 <br />