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INVENTORY RECOrIcILIATION <br />QUARTERLY SUMMITRY REPORT FORM <br />Facility N,,,: �. <br />_ Tank f Size <br />Product <br />PaC. ity Address: `G <br />C <br />Telephone: <br />Person Fi g <br />Report <br />I hereby certifyunderpenal[ of e <br />the above y perjury that all inventory variations for <br />mentioned facility were viChin the allowable limits for this <br />quarter. (Ho in Column 13 of the Inventory Reconciliation Sheet) <br />Q Inventory variations exceeded the allowable Limits for this <br />herebycertifynames quarter: I <br />penalty of perjury that the source for the variation <br />was not due to an unauthorized (leak) release. (Yes <br />Inventory Reconciliation Sheet) in Column 13 of the <br />List date, tank /, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank # Amount <br />1. <br />0 <br />2 <br />3. <br />4. <br />Additional daces/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 <br />Within 24 hoursand an unauthorized r(•lease reporEt sDubmiirced�n�ntal �lealth <br />The quarterly summ.]cy repot[ shall be .ubmitted vi[hin IS }aye nl the end u <br />quarc��r, f <br />Quarter I - Janunry --, Harch <br />Q'lartec 2 April --> June <br />Quarter I - July --> :;epternher <br />QI,arcer 4 - October --> <br />t)ecemt)ec <br />..end co: SAN .JOAQUIN LOCAI, HEALTIi I)I5i'1tICT <br />1601 p. Hazelton, P.0. Box 2009 <br />11CT 40 10/86 Stockton, CA 95201 466-6781 <br />