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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM pUl 1 <br /> 1988 <br /> Facility Name: ��� ! ���1 Tank / E:' S ` ";`r gVIClSroduct <br /> Facility Address: �— \ GC� %0 Mme) <br /> I Cn <br /> Telephone : <br /> Person Fill `n <br /> Report " cam\� v v `I tiV"2-VVkU�' <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 Column 13 of 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 /> was 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 /> Date Tank / Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> if the source of the variation which exceeded allowable limits wns due to <br /> , <br /> a leak the incident shall be reported to S ,J .j„1L D. Environmental 11calth <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter i - January --) Kirch <br /> Q,iacter 2 - April --> June <br /> (hurter 3 - July --) September <br /> Quarter 4 - October. December <br /> Send to: SAN JOAQUIN 1,OCAL 11LALTH DISTRICT <br /> 1601, E. . 1117,e ] ( 011 , p .0 . 11” 2009 <br /> S(ocicton , CA 95201 466-6781 <br /> 1ICT 40 10/86 <br />