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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> �pTank / Size <br /> Facility Name: �M�17� ��- O(-� - <br /> Product <br /> l IDr;co ia1uJ <br /> Facility Address: ODo 1 <br /> C� lz LA eco <br /> oar 1 <br /> 'telephone : 2bgr <br /> Person Filin \ �^ <br /> Report c . 5 °'1 kL.1A<yv%r: <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 ttie <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I 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 was due. to <br /> a leak the incident shall be reported to S .J .L.11. 1) . Environmental Health <br /> Within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within 15 days of tile. end of each <br /> quarter. <br /> Quarter I - January --> "arch <br /> Q•�a rter 2 - April --> June <br /> (hurter 3 - -laity --> Septemher <br /> Qjarter 4 - October, --) December <br /> Send to: SAN JOAQUIN LOCAL 11LALT11 DISTRICT <br /> 1601 1" . I1azeIton , I' .0 . Box 20()9 <br /> SLockton , CA 1)5201 466-6781 <br /> UGT 40 10/86 <br />