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ja t j <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM 1,iEALTH <br />raciuty Name: <br />u&vn IXIMART <br />Faci1ity,Address:14971 N. Hwy. 88 <br />. <br />Telephone: <br />Person Filing <br />Report <br />Tank i ize Product <br />U UNLEAD�j <br />n <br />�. <br />© I 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. (No 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 the source for the variation <br />was not due to an unauthorized (leak) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank 1, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank i Amount <br />1. <br />2. <br />3. <br />4. <br />S. <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 allowable 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 I - January --> March <br />Quarter 2 - April --> June <br />Quarter 3 - July --> Septemht!r <br />Quarter 4 - October --> December <br />Send to: SAN JOAQU IN LOCAL HEALTH DISTRICT <br />1601 E. Hazc 1 t nn , P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />T 40 10/86 <br />