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Iftor <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Nage: �{lG/!S L.- ,l/ — Tank f Site Product <br /> Faeilaty4ddress: J � I''=i/]XST/1//tL /l• <br /> 57-n <br /> Telephone : <br /> Person Filin <br /> ReportT/��VLEy /Ai�/�/71�5 <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 Colusn 13of 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 /> vas not due to an unauthorised (leak) releise. (Yes in Colu— 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date. tank I. and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank / Amount <br /> 1. <br /> 2. <br /> J. <br /> 4. <br /> 5. <br /> Additional daces/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. exceeded at lovable 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 /> The quarterly su—,ry report shall be submitted within 15 days of the end of each <br /> qu.rter. <br /> Quarter I - January --) March <br /> Qaarccr 2 - April --> June <br /> Quarter 7 - July --) September �. <br /> u rtcr 4 - October --) December <br /> Send Co: Q� APR (? 'Q' <br /> SAN JOAQUIN L(ICAI, HtAL1'li UIS'I'KIC'I' <br /> 1601 E . (laze I ( (,n , P -0 fiox 2009 ENVIROMENTAL HEALTH <br /> SCOXton . CA 95201 466 - 67bl FERMIT/SERVICES <br /> 40 l0/N6 <br />