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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> �4 O e <br /> Faciiity. Hamer ( e �Y w ,C OC�fC'Ips( 'tank # Si Product <br /> Gam• <br /> Pacilaty,'Addreas: <br /> P <br /> Telephone : <br /> Person Filing <br /> Report ��e � <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. (Ho in Columna 13of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury'tha't the source for the variation <br /> vaa not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) _._. <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits_ <br /> D Vu�Date Tank I Amounti. n- 1� <br /> 2. tEU�- n 11987 <br /> 3. ENViRQMENTAL HEALTH <br /> 4. <br /> FERMIT/SERVICES <br /> S. <br /> Additional dates/amounts shill be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation vhich rrcrcdcd allowable limits was due to <br /> a leak the incident shall .bc rc1*,�c t _J t() S ..J . L , 1i . D . Environmental Health <br /> within 24 hours and an unauthorized relcase report submitted. <br /> The quarterly suwmary report shall br F.ubmit.te.d vithin 15 days of the end of each <br /> quarter. <br /> Quarter 1 - January --i Harch <br /> Quarter 2 - April - > J-,o.• <br /> Quarter ) - J„17 <br /> Quarter. 4 - Octobrc <br /> Send to: SAN .J CiAQU 1;. 1J.P-'.r,2, HEAl_'Fi: r11 :>TH l'CT <br /> 1601 1()(1`7 <br /> Stockron , r-A `15,201 46(i - 6-lh1 <br />