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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY RF-PORi FORM <br />14— <br />FAt LiCy Name: / liJi/yy/6-y,�It✓/D(a4/ <br />Facility Address: A.% 'nQ.,�o <br />-11�414 Zo y <br />Telephone: <br />Person Filing <br />R�� /�E <br />Report <br />ort � <br />M• heccby rectify under penalty of perjury that all inventory variations for <br />the above meacioned facility were within the allowable limits for this <br />quarter. (No is Column 13 of the lnvenCory Reconciliation Sheet) <br />Iaveatocy variations exceeded the allowable Limits for this Quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to an unauthorized (leak) release. (Yes is Column 13 of the <br />Inventory Reconciliation Sheet) <br />J <br />List date, tank /, and amounC for all variations that exceeded the <br />allowable limits. <br />1. <br />2. <br />3_ <br />4. <br />5. <br />Date Tank f AmounC <br />r <br />Ar <br />ENTH <br />FERidll/SERVICES <br />Additional dates/amouacs shall be concioued on a separate sheet of <br />paper and atCached. <br />Lf the source of the variation which exceeded allouable limits was due to <br />a leak the incident shall be reported to S.J.L.H.D. Environmental Ilealch <br />Within 24 hours and an unauchoriscd release report submitted. <br />The quarterly suo.mary report shall be .ubmitced within 15 days of the end of each <br />quarter. <br />Quarter I - Janu.ry --) March <br />QQurccr 2 - Apri l --> Jan,: <br />Quarter 1 - July --) Scptcmber <br />Quarter 4 - October --> December <br />Send co: SAN JOAQUIN 1.0CA1. HEAI.TIi 01STRICT <br />1601 E. Hazellnn. V.0. Ilex 7O()9 <br />Stockton, CA 1)5201 466-67bl <br />LICT 40 10/86 <br />