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INYENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name; <br /> Tank I <br /> Size Pcodu t <br /> Facility Address: <br /> Telephone : <br /> Person Filing <br /> Report i2�iZ:::: <br /> I hereby certify wader <br /> the above the of perjury that all inventory variations for <br /> Penalty <br /> facility were within the allowable liaits for this <br /> quarter. (No in Coluaaa 13 of the Inventory Reconciliation Sheet) <br /> "ventocy variations exceeded the allowable Limits for this u <br /> hereby certify under penaltyof quarter. I <br /> per jury that the source for the variation <br /> was not due to ao unauthorized (leak) cele::e. (Yes is Column U of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank I, and amount for all variations that exceeded the <br /> allov®ble liatiics. <br /> Date Tank I Amount <br /> 1. <br /> I V,!' L U <br /> 3. <br /> 4. 199 <br /> S. ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> A.dditiooal dates/amounts shall be continued on a separate sheet of <br /> Paper and accached. <br /> Lf the 'source of the variation which <br /> exceeded allowable limits was due to <br /> a leak the incidenc shall be cerocced to S ,J . L. H . D. Environmental 11calch <br /> within 24 hours and an una°tchorizcd release report submitted. <br /> the quarterly summary report shall b` ,submitted with' <br /> n IS days of the end of eact, <br /> January --> H.1.ch <br /> Q•A.1 rcer 1 - Airs t --> Jun°• <br /> QkAarCer ) - July --) September <br /> Q�Aarcer 4 - October <br /> k c�mbe r <br /> Send to: SAN JOAQUIN LOCAL HEA1.1.1. DIS-1-HICT <br /> 1 60 1 E . i;�zc• I t eui , 1° .() . Ht,x I0O°) <br /> �°U l 0/li 6 :iLockcon . CA 95101 466 -61b1 <br /> 1' <br />