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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />raciLity Name: <br />Tank size <br />siSi <br />radli.ty4ddress- C A 9 52- 4 0 <br />ze <br />Telephone:/do Cad <br />Person Filing <br />Report <br />......... <br />2a a� . z <br />I hereby certify under pecalty <br />of Perjury that 411 inventory ,sri <br />the above ti ed facility were within the allowable limitsV <br />quarter. (_N0 in Column 13 of the for atithis... for <br />10"QCOU Reconciliation Sheet) <br />Inventory variations exceeded the allowable limits for tbid quarter. 1 <br />hereby certify under Penalty of perjury that the source for the variation <br />was not due to An unauthorized (leak) re]Le�ae. (yen in <br />Inventory Reconciliation Sheer- <br />., a:: <br />aad amount for all variations that exceeded the <br />allowable limits. <br />Date Tank Amount <br />1® <br />2. --------- -------- ------ <br />3. --------- -------- <br />----------- ------ <br />4® <br />- ----------- ------ --------- <br />OCT I I 1'l <br />ri <br />L <br />IT <br />Additional dates/ZmOuats shall be continued on a separate sheet of <br />Paper need attached. <br />If the source of the variation which.cxceeded atlowabt, limits was due to <br />4 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 />ne quarterly summary report shall be submitted within 15 days of the end of each <br />quarter® <br />Quarter I - January March <br />Q'14rter 2 - April Jurve <br />Quarter 3 - July septecahcr <br />Qwjartcr 4 - October December <br />Send to. SAN JOAQUIN LOCAL HEALI-Iii DIS -1 -RIC -1- <br />1601 E. Ila zelton, 11.0. Ito.,< 2()()g <br />40 10/86 Stockton, CA 95201 460-67b1 <br />