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u /qgl <br /> , P 1 <br /> INVENTORY RECONCILIATION 4. <br /> QUARTERLY SUMMARY REPORT FORM <br /> . C° �P <br /> 'j Facility Name: <br /> Tank <br /> s"ie Prod t <br /> Pscility Address: <br /> -� <br /> Telephone : `z Z <br /> Person Fil <br /> Report . <br /> MA <br /> hereby certify under enact of <br /> Penalty 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 /> 9 <br /> ElInventory variations exceeded the allowable limits for this quarter. I <br /> hereby certifyunder <br /> 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 /> k Inventory Reconciliation Sheet) <br /> List date, tank f, and :mount for all variations that exceeded the <br /> s allowable limits. <br /> ' Date <br /> Tank I Amount <br /> 4 <br /> 2. <br /> 3. <br /> 4. <br /> S. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> h <br /> raper and attached, <br /> 'Y <br /> If the source of the variation which. exceeded at-lowable limits was due to <br /> At 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 The quarterly summac <br /> y report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter 1 - January --> March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> Ikkcember <br /> Send to: SAN JOAQUIN LOCAL HEAL1.1i DISTRICT <br /> 1601 E. Hazelton . P .O . Box 2009 <br /> Uc,'T 40 10/$G Stockton , CA 95201 466-6781 <br />