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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM x,ASa <br />tbdi� <br />Facilit' Name: m(c_ <br />SSP ME< i <br />Fac. icy Address: Of <br />Telephone: <br />Person Fiji -- <br />Report Z/ <br />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. (Ho 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 <br />was not due the source for the variation <br />to an unauthorized (leak) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date$ tank 19 and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank # A=)unt <br />2- <br />3. i <br />4. <br />5. <br />Additional dates/amounts shall be continued on a separate sheet <br />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 Eiealth <br />within 24 hours and an unauthorised rm•lease report submitted. <br />The quarterly summary report shall be .ubmit[ed within IS dJys of the end of r,-Jch <br />quarC��r. <br />Quarter I - January --> March <br />Q'larter 2 - April --> June <br />Quarter 3 - July --> Sep[cmhc-r <br />Q`aar[er i. - October --> December <br />-en<9 to: <br />11CT 40 10/86 <br />SAN JOAQUIN LOCAL 111:ALTH DISTRICT <br />1601 F. Hazelton, 11.0. Box 2009 <br />Stockton, CA 95201 466_6781 <br />