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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY RCPORT FORM <br /> FaeiLity Name; Tank I Sire Product <br /> [aeility;Address: SQ A =7,o <br /> • rYS L /r <br /> Telephone : Z <br /> Person Filing <br /> Report S'/�-iyyr � % 771,,�k� <br /> I 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 13of the Inventory 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 not due to an unauthorized (leak) releiae. (yes in Column I] of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank ! Amount <br /> 1. <br /> 2. <br /> 1. <br /> 4 ENVIkU wtr4Ai HLALT <br /> FERfv111/SERVICES H <br /> 5. <br /> Additional dates/amounts shall be contioued oa a separate sheet of <br /> paper and attached. <br /> if the source of the variation -hich. exceeded allowable limits was due to <br /> A leak the incident shall be reported to S .J . L. H . D . Environmental Health <br /> within 24 hours and an unauthorized release report submitted. <br /> ITe Quarterly summary report shall be submitted within 15 days of the end of each <br /> Quarter_ <br /> Quarter I - January --) March <br /> Qu r t ct© - April --) June <br /> Quarter ) - July --> ;epCcmh,:r <br /> Quarter 4 - October --> nccrmber <br /> Send to: SAN JOAQU IN LOCAL HEALI H D ISI R ICC <br /> 1601 E . Hazelt4wn . 1' . 0 . Hoo 2009 <br /> Stockton , CA 95201 466 -67bi <br /> 40 l0/N6 <br />