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MAR 3 0 1992 <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM �c,sv; <br /> FaciL,ity Name: P�'Q� // 1 <br /> Oc/CP Tank f •: 1 Size. Product <br /> PdciLity Address: 470,37 Es el <br /> oc�Ce <br /> voD ri <br /> Telephoner 7.2.7 1f44 3 dOD �7 <br /> Person Filing <br /> -- <br /> Report /7 <br /> v e <br /> 0 Cr <br /> I hereby certify under Pena It <br /> y of perjury that all inventory variations for <br /> the above menItioned facility were within the allowable lisiits for this <br /> quarter. (No in Column 13 of the Inventory Reconciliation �Sheet) <br /> ❑ Inventory variations exceeded the aLlovable' Limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to ao unauthorised (leak) release. (Yes is Column 13 of the l <br /> Inventory Reconciliation Sheet) , <br /> List date, tank fi aud ,nmount for .all variations that exceeded the <br /> allowable limits. <br /> Date Tank F Amount <br /> 1. 1 <br /> 2. <br /> 3. <br /> 4. <br /> 5 I <br /> Additional dates/amounts shall be continued ou a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. exceeded allowable limits was due to <br /> a leak the incident shall be reported to 5 ..7 . L. 11. D. Environmental Health <br /> within 24 hours and an unauthorized release report submitted. <br /> f <br /> The Quarterly summary report shall be Fubmitted within 15 days of the end of each <br /> quarter. <br /> I <br /> Quarter 1 - January --> March <br /> Quarter 2 - April --> Jure <br /> Quarter 3 - July --? September <br /> Quarter 4 - October ---> [keember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160 ! E. Haze1Lo n , P .O , 11()x 2O()g <br /> Stockton , CA 95201 466-6781 <br /> UCT 40 10/ 86 <br />