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6 INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility <br />Facility Address: <br />Telephone:g L(' <br />Verson Filing <br />Report: l t S Sow. <br />Tank # <br />Size Product <br />March <br />cc) <br />Quarter 2 -- <br />April --> <br />June <br />1 u U-U\,)T4 4 Al c <br />Quarter 3 - <br />uarter - <br />July-> <br />October --> <br />September <br />December <br />Y } <br />[] I Hereby certify under penalty of perjury that all inventory <br />variations for the above mentioned facility were within the allowable <br />limits for this quarter. (No in Column 13 of the Inventory <br />Reconciliation Sheet). <br />[ ] Inventory variations exceeded the allowable limits for this quarter. <br />1 hereby certify under penalty of perjury that the source for the <br />variation was not due to an unauthorized (leak) release. (Yes in <br />Column 13 of the Inventory Reconciliation Sheet). <br />List date, tank #, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank # Amount <br />2. <br />3. <br />4. <br />5. �r <br />Additional dates/amounts shall be continued on a separate sheet of <br />paper and attached. <br />if the source of the variation which e..ceeded allowable limits was due <br />to a leak the incident shall be reported to S.J.L.H.D. Environmental <br />Health within 24 --hours and an unauthorized release report submitted. <br />The quarterly summary report shall be submitted within 15 days of the <br />end of each quarter. <br />Quarter 1 -- <br />January --> <br />March <br />Quarter 2 -- <br />April --> <br />June <br />Quarter 3 - <br />uarter - <br />July-> <br />October --> <br />September <br />December <br />Y } <br />Send to: <br />SAN JOAQUIN <br />LOCAL HEALTH DISTRICT <br />PJ ��� 89 <br />1601 E. Hazelton, <br />P. 0. Box 2009 <br />,1A <br />Stockton, <br />CA 95201 466-67$1 <br />���vlr ;., . ITfjT HFALTH <br />PLRIIAIT ! SERVICES <br />T 40 10/86 <br />