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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: 4i ,XI( ,e <br />Facility Address: 'A6/ € <br />Telephone: Sir- SISiL <br />Person Fil g <br />Report j <br />1 hereby certifunder 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 />QInventory variations exceeded the allowable limits for Ibis quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to aa unauthorized (leak) releiae. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />i <br />List date, tack f, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank E Amount <br />1. <br />2. <br />3. <br />4. <br />5. <br />Additional dates/amounts shall be continued on a separate sheet of <br />paper and attached. <br />It 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. Environmenta 1 Ilca I t Il <br />w►thin 24 hours and an unauthorized release report submitted. <br />The Quarterly summary report shall be aubmicted within 15 days of the end of e.ich <br />Quarter. <br />Quarter I - January --) March <br />Quarter 2 - April --) June <br />Quarter 3 - July --) Septcmher <br />�( Q—Irter 4 - October --) (k-cember <br />Send to: SAN J0A00IN UWAL HEAL'1'1i DISTRICT <br />1601 1•.'. H ze l Inn . V .0 . Rox x(1(19 <br />Stockton. CA 95201 466-67b1 <br />1' 40 10/80 <br />� An <br />JUN 15 1988 <br />ENVIROMENTAL HEALTH SLTH <br />