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tai 1a <br /> INVENTORY RECONCILIATION RV;, Ea <br /> ::J QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: <br /> 'tank € Sixe Prod ct <br /> Facility Address 4 176 Ai. <br /> Teleph e : <br /> Person F ng <br /> Report <br /> I hereby certify under Penalty of <br /> that all <br /> the above mentioned facility were within ythe allowableentory lim tsvarifor$tithiss ter <br /> quarter. (No in Column l3 o€' the Inventor Reconciliation Y illation Sheet) <br /> Inventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to an unauthorized (leak) release. (Yes in Col <br /> Inventory Reconciliation Sheet) 13 0¢ the <br /> List date, tank t#, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Yank € 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 /> If; the•` source of the variation which. exceeded a plowable limits was due to <br /> a 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 /> The quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter 1 - January --> March <br /> Quarter 2 - April --> Juno <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> ('Comber <br /> Send to: SAN ,JOAQUIN LOCAL HEA1_T'1i UISTRIC'1' <br /> 160 1 E . E:arc' 1 t r,n , P .O . Box 2009 <br /> Uc;T 40 10/86 SCockton . CA 95201 466-67b1 <br />