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¢ 6 <br /> INVL'N't'o12Y itECONCILIA`I°ION <br /> QUARTERLY SUMMARY REPOR`i' FORM <br /> a racilit:y Name: ' <br /> a or./ Tank # Size ! ' Product <br /> u r 1`ac:i'lit:y Address: <br /> _JazASI e- <br />'V elophorle: O <br /> Pctr:son..Filing . <br /> r <br /> i hereby certify under penalty of perjury that all inventory variat. <<.5r <br /> for the above mentioned facility were within the allowable limits <br /> t €a; <br /> k this quarter. <br /> ( No in Column 13 of the Inventory _Reconciliation Shec . ,. <br /> k <br /> i <br /> Inventory' variaL-ions exceeded the allowable limits for this quarter <br /> hereby, certify under penalty of <br /> I y perjury that the source for the va, ,. <br /> tion was not due to unauthorized ( leak) release. (Yes in Column 1:.3 �a <br /> Ari <br /> the ,Inventory Reconciliation Sheet) . � <br /> List date, tank , and amount for all variations tha " <br /> the allowable limits. <br /> Da to Tank <br /> 'r' _. ...._ Rma u n lVEL <br /> MAY <br /> - 1 TAL EALT <br /> z. TSE <br /> ,a VlCE <br /> 4 . 1 <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet <br /> paper; and attached. <br /> It he source ,of the variation which" exceeded allowable limits was <br /> due toleak, the incident shall be reported to San ,Joaquin Local <br /> ` Health District, Environmental health Division, within twenty-four <br /> -2 } hours ..,°and an unauthorized release report submitted. <br /> quarterly sunm y report shall be submitted within, fiftreen (15 <br /> cit the. end of eac uartMer. ) da ys <br /> cx <br /> A <br /> S d <br /> Quarter 1 Januar <br /> A r y_ - -__>March <br /> Quarter 2 April------------>june <br /> z <br /> Quarter 3 July--------- <br /> >Sc ateantaer <br /> 33 uarter. 4 <br /> Q October----------->December <br /> SAN JOAQUIN LOCAL Ht: STH DISTRICT <br /> 1601 E. Hazelton, P.O. Box 2009 <br /> tockton, CA 95201 468-3420 <br /> t <br /> 96 <br /> �i <br /> .s€ `e }�{ Y■ {y <br />