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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Names - y Tank f Size. Product <br /> r..tttcy;Addre..: 950,2, Oa <br /> G T <br /> Telephone : ZD 9 _ 9dL <br /> Person Filing <br /> Report Geio <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> the above neacioned facility were within the allowable limits for this <br /> Quarter. (No in Colum 13 of the Inventory Reconciliation Sheet) <br /> ❑ Inventory variations exceeded the allowable limits for this Quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> wan not due to an unauthorized (leak) release. (Yes in Col— 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tack /, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank / Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amouacs shall be continued on ■ 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 [Ica lth <br /> within 24 hours and an unauthorized release report submitted. <br /> The Quarterly summary report shall be submitted within 15 days of the end o <br /> Quarter. U <br /> Quarter 1 - January --) March X( <br /> Q.arter 2 - April --> June <br /> Quarter 7 - July --> sepcemhcr <br /> Q.artcr® - October --> (kccmbcr <br /> Send SAN JOAQULN LOCAI. HEAL1'li t)t S-1'I( t(: <br /> co: <br /> 1601 E . Hazeltr.n , P .O . Ito x 2009 <br /> Stockton . CA 95201 466 -67b1 <br /> LILT 40 10/ 86 <br />