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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: /��G C? Iii <br />Facility <br />Telepho <br />Person <br />Report <br />Tank I Size Product <br />/2mm0 <br />y <br />✓ e v <br />L 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 CoLu® 13 of the Inventory Reconciliation Sheet) <br />C1Inventory variations exceeded the allowable limits for this Quarter. T <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to as unauthorized (leak) releaae. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) F <br />r <br />List dates tank fp and amount for all variations Chat exceeded the <br />Allowable limits_ <br />3. <br />4. <br />5- <br />Date Tank I Amount <br />f <br />ERVIR0M,E :TAL HEALTH <br />HW11T/SERVICES <br />Additional dates/amouacs 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 lleatch <br />within 24 hours and an unauthocized -r%lease report submitted. <br />The Quarterly summary report shall be submitted within 15 days of the end of each <br />Quarter_ <br />iarccr 2 - April <br />Quarter 1 - July __) septcmher <br />Q�.arter 4 - October --> th:crmher <br />Send to: SAN JOAQUIN LOCAL HEAI.TIi DISTRICT <br />i <br />1601 E. Haze l t nn • V.0- Iter 2007 <br />SLockton• CA 952U1 466-67bl <br />UCT 40 I0/86 <br />