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I -ENTORY RECONCILIATION D �J <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: <br /> Alm ��� Tank# Size Product <br /> Facility Address: �� � ���� <br /> Telephone: Cy 3 <br /> Person Fi <br /> Report: <br /> I hereby certify 'under penalty of perjury that all inventory variations for <br /> the above mesciomed facility were within the allowable limits for this <br /> quartar. (He in column it of the Inventory acconciliation Sheet) <br /> a <br /> s< <br /> Inventory varintibas exceeded the allowable limits for this quarter. ' I <br /> beraby certify vender penalty of perjury that the source for the variation <br /> was oat due to an unauthorized (leak) release. (Yes in Colum 13 of the <br /> Inventory Ratonciliatial: Sheet) <br /> List dates task f, and amouat for all vaciatload that exceeded the <br /> allowable limits. <br /> Date Tank a &M2—unL <br /> 1 <br /> • u auz <br /> 2. 21i2 .s -ZS 1 <br /> 3 . <br /> 4 .- -- 1 - iya 7 tion <br /> 6. /7 - 1 . . <br /> 7. 2G Z9 a 2 <br /> e. 'S _ s� <br /> 10. <br /> 13. 11j --4 /65- <br /> 14.___V- 5 Z <br /> 15. 6 . 7 <br /> 16. g• /V -� -3io <br /> 9/ <br /> 17. 7e zY z N� r -2 2T <br /> 18. - 5 <br /> 19. 3 - /y <br /> 20. /5. <br /> 21. 7 <br /> 22. 7 :Lie, <br /> 23.�7� <br /> 24. <br /> 25.— /o <br /> 26 <br /> 27. <br /> 28. <br /> 29. <br /> 30.��_ <br /> 31.x_ <br /> Addiciooal dates/amounts shall be continued on a separate shoat of <br /> paper and sccaahed� - -- <br /> If the source of the variation which- exceeded allowable limits <br /> was dudoatchd ca, <br /> a task the incident shall be reported to S.J .L.H.D. <br /> within 24 hours add an unauthorized release report submitted. <br /> Ibe quarterly summary report shall be submitted within IS days of the and of each <br /> quarter. <br /> Quarter 1 - Jaauary --> March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> Oaccmber <br /> Seed ce: SAN JOAQUIN LOCAL HEALTH DIS'rHICT <br /> 1601 E. Ilaze l e4u1. 1, .0 . I►nx 2009 <br /> • Stockton . CA 95201 466.67b1 <br /> 40 10/86 <br />