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/• r v <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY RsPORT FORM <br /> Facility Name: U Tank 1 Size Product <br /> Facility Add re a a: <br /> 9J" <br /> Telephone : / <br /> Person ;iii g <br /> Report _�Clnr <br /> ® L hereby certify under penalty of perjury that all inventory variations for <br /> the ebove sxationed facility were within the allowable limits for this <br /> tuarter- (No in Column I)of. the foventory Reconciliation Sheet) <br /> 0 Inventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was DOC due CO ao unauthorized (leak) releise. (Yes in Column 13 of the <br /> Loventory Reconciliation Shcec) <br /> List dater tank /. and amount for 311 variations that exceeded the <br /> allowable limits. <br /> Date Tank / Amount <br /> 1. <br /> 2. <br /> 7. <br /> 4. <br /> 3. <br /> Additional dates/amounts shall be continued oa 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 rcpocted to S ,J .1_11.r). Environmental Iicalth <br /> Within 24 hours and an unauthorized release report submitted. <br /> The quarterly sump ry report shall be subeitted within IS days it the end of each <br /> quarter. <br /> Q Arcer 1 - January --) March <br /> Qrarter 7 - April --> June <br /> .Q/arter l - July --) ,ieptember <br /> Qiarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HFAI.TU DISTRICT <br /> j I001, r. Haz4• 114n1 , P .0 711114 <br /> St �lrkuat , CA 1020 <br /> 111:•1• 40 101811 <br />