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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> 1raduty, Names / / 11Z)/--r1kF1t Tank # Site. Product <br /> S./�/. e <br /> PaeilLCy Addreus �i S �9 Z C Ga C�cp. - a ut <br /> Telephone : (2/ 3) <br /> Person Filin° <br /> Report <br /> 0 1 hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (No in Column I3of the Inventory Reconciliation Sheet) <br /> 2 <br /> m <br /> Inventory variatibas exceeded the allowable limits for this quarter. ' i <br /> hereby certify under penalty of perjury that the source for the variation <br /> was sot due to an unauthorized (leak) relel'se. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date# tank fv and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank ! Amount <br /> 1. loll As-7 U7 - / L/5- <br /> 2. 30.7 <br /> 7. <br /> 10J ,3 o7- <br /> 4. /o / C//,<r7 307 -/ a95- <br /> 5. �v 1�7 307-/ /S a -i- <br /> Additional dates/amouets 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 Uealth <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter 1 - January --> March <br /> Quarter 2 - April June <br /> Quarter 3 - July --) September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH UIS1•KICT <br /> 1601 E. 11aZeIL011 • P -O - Box 2009 <br /> SLockton • CA 95201 466-6781 <br /> :;T 40 10/86 <br /> yS- <br /> Co , / ?3- /S <br /> -rg�c - <br /> 1 , . lilwl&,7 307 - /.03t o7- a 4i7f <br /> /-7 /a /a8/9? 3 <br /> 30,7- � 9!0 — /fr 7/� 7 307- -3 bFf <br /> 9 <br /> 1111-71r-7 30-?- a aS— <br /> /9 /-2./�23/8 �• 307-3 90 - <br /> )O111-2gA7 307- a l U3- 90 /x/ 7/87 307-1 6) 7C/— <br /> / , l//a/4-7 30-7- 3 / ya _ � / /ezl/i /p7 307 - / 857- <br /> �� lll�, / 87 307-1 <br /> /3 /// 'a-/87 3o�- I 10-7- <br /> 3o7- <br /> 07- <br /> 3o7- 1 volf <br />