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ENTORY RECONCILIATION <br /> QU ERLY SUMMARY REPORT FORM <br /> Lawrence Livermore <br /> Facility Name: National Laboratory Tank Size Product <br /> 879-G1U1 10,000 Gal Re ular Gas <br /> Facility Address: P.O. Box 808 L-633 879-G2U1 10,000 Gal Unleaded Gas <br /> Livermore CA 94550 <br /> Telephone: (415) 422-5167 <br /> Person Filing <br /> Report: Joe Kiefer <br /> I hereby certify under penalty of perjury that all inventory <br /> variations for the above mentioned facility were within the <br /> allowable limits for this ( <br /> .uarterNo in column 13 of the <br /> q _ <br /> ve oReconciliation Sheet. <br /> In nt ry ) <br /> Inventory variations exceeded the allowable limits for this <br /> quarter. I hereby certify under penalty of perjury that the <br /> source for the variation was not due to authorized (leak) <br /> release. (Yes in Column 13 of the Inventory Reconciliation <br /> Sheet) . ( <br /> 00, <br /> List date, tank #, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Date Tank Amount Reason <br /> 1. (SEE ATTACHED TABLE 1) <br /> 2 <br /> 3 <br /> 4 <br /> 5. <br /> Additional dates/amounts shall be continued on a separate <br /> sheet of paper and attached. <br /> If the source of the variation which exceeded allowable limits <br /> was due to a leak, the incident shall be reported to Public <br /> Health Services of San Joaquin County Environmental Health <br /> Division, within twenty-four (24) hours and an unauthorized <br /> release report submitted.- <br /> The <br /> ubmitted.The quarterly summary report shall be submitted within fifteen (15) days of <br /> the end of each quarter. Circle appropriate 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 PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. Hazelton Ave. , P.O. Box 2009 <br /> Stockton, CA 95201 <br /> (209) 468-3420 <br />