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INVENT <br /> ORY <br /> QUARTERLY SUM AROYNR PORT�OFORM ENM1%SEEStH <br /> vFERM <br /> Facility Nano: Mprc��. <br /> - <br /> [.eility Addre.s: 95c� <br /> Telephone : <br /> Person Fiji Z2 <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 CoLumm I3of the lnventory 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 so unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank /, and amount for all variations that exceeded the <br /> allowable limits_ <br /> Date Tnak / Amount <br /> 1. <br /> 2. <br /> 3. — <br /> 4. <br /> 5. <br /> Additional daces/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> if the soucce of the variation whichexceeded allowable limits was due to <br /> A leak the incident shall be reported to S .J . L . N . D . Environmental health <br /> within 24 hours and an unauthorized release report submitted. <br /> ITe Quar Lerly summery report shall be Rubmitted within 15 days of the end of each <br /> Quartcr. <br /> Quarter I - January --) March <br /> Q•Aarter 2 - April --> Junc <br /> Quar ter - July --> Scptcmhrr <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAI. 11EAL"1'1i DISTRICT <br /> 1601 E . Hazcltnn . P . O . Itns 2009 <br /> SLO(:Yt*ton • CA 95201 466 - 67b1 <br /> 40 l0/H6 <br />