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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> raeiU.ty. Nears Tank Size. Product <br /> [ieilitp:Addrasss71 <br /> 7 <br /> Telephone: 0) 33-93(oG� Oct S�O�_ <br /> Person Fil <br /> Report �Y <br /> 0 1 baceby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (N_ in Colum 13of the Inventory Reconciliation Sheet) <br /> n <br /> Inventory variatibes exceeded the allowable limits for this quarter. ' i <br /> baceby 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 dates tank /t and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank ! Amount <br /> 2. :�h2- 30 - /�+u PV { <br /> 4. -s — <br /> -y»- 37--- 4A/t ., 9� -- <br /> -7` <br /> 0 __ / <br /> — / 3 <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 /> quarterly summary report shall be submitted within IS days of the end of each <br /> qu rter. <br /> Quarter 1 - January --> March <br /> Quarter 2 - April --> June <br /> Quarter ) - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH UIS"l'RICT <br /> 1601 E. liaze1ton . P .0. 110X 2009 <br /> Stockton . CA 95201 466-6781 <br /> ;T 40 10/ <br /> /5 D t leu /30 <br /> KS — <br /> ' n. � �fl/� - 2C� 317- • <br /> U �{ a <br />