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`f <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Faeitity Name: % A!2 � tank i Size. <br /> Product <br /> FaeitityvAddress: ,SDT �� v0 vH6 <br /> d <br /> Telephone : Zp T — 51R _p a <br /> Person Filing <br /> Report <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 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 /> was not due to an unauthorized (leak) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> Gist date. tank 1, and amount for all variatioas''th t exceeded thee. <br /> allowable linits. <br /> Date Sank i Amount ENVIRUMLVIAL HEALTH <br /> 1. F ERIA11/SERVICLS <br /> 2. <br /> 3. <br /> 4. <br /> S. <br /> Additional dates/amouats shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation whichexceeded allowable limits was due to <br /> A leak the incident shall be reported to S .J . 1— H . D . Environmental Health <br /> within 24 hours and an unauthorized release report submitted. <br /> The Quarterly summary report shall be submitted within 15 days of the end of each <br /> Quarter. <br /> Quarter(D— January --) March <br /> Quarter 2 - April --) June <br /> Quarter 3 - July --) scptcmh.�r , <br /> Q%.ar[cr 4 - October --> december <br /> Send to: SAN JOAQUIN LOCAL HEAL1'1i DIS-IRIC'1 <br /> 160L E. Ilazelton . P . O . Kox 2009 <br /> SLOCKCOn . CA 95201 466 - 67b1 <br /> 40 10/86 <br />