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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facil,icy Name: C;=e4 Z. Le:a�­C- Tank f Size. Product <br /> el <br /> Facility�Addresa: <br /> Telephone : ��U� - 7'�7�`�-7- <br /> Person F'ilin <br /> Report P <br /> hereby certify under peaalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (Ho in Column 13 of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable limits for thin quarter. I <br /> hereby certify under penalty of- perjury that the source for the variation <br /> was not due to as unauthorized (leak) release. (Yes in Colum 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, Asad amount for all variations that exceeded the <br /> allowable lictita_ <br /> Date 'Tank # Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5_ <br /> Additional, datc_s/amounts shall be continued on a separate sheet of <br /> paper and atCached. <br /> It the source of Chr variation which. cxcecded allowable limits was due to <br /> a least the incident shall be reported to S J L . U • D_ Environmental Health <br /> Within 24 hours and an unauthorized release report submitted. <br /> The quarterly summarry report, shall be rcubmitted within 15 days of the cnd of each <br /> quarter. <br /> Quarter l - January --) Harch <br /> (�Jartcr 2 - April --) Junc r5 <br /> Qua rtcr ? - July --) septemh'-r <br /> AN <br /> JZ, j 'I1 <br /> Quart.cr 4 - Oc-c.obcr --) Dh_Ccmbrr <br /> iEIVV ir2,�,,,�,, . _ 's!FNI.T�i <br /> send t<�. N _I(,,/�QU I N t-M.;AL HEAL1'1' D] STR i C'I PER1vlfl f�kE2VICES <br /> 160i I-: . 1, 0 ., 11r�x 2009 <br /> .Si ockc.on , .(.'A 95201 466 - 6761 <br /> 11('T 40, 1 0/ �W <br />