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Facilil <br />Faciiit <br />Telepho <br />Person <br />Report: <br />r <br />0 <br />0* 00 <br />INVENTORY RL:CONCILIATION <br />QUARTERLY SUMMITRY REPORT FORM <br />I hereby certify under penalty of perjury that .all inventory variations <br />for the above mentioned facility were within the allowable limits for <br />this quarter. (No in Column 13 of the Inventory Reconciliation Sheet.) <br />Inventory variaLions exceeded the allowable limits for this quarter. I <br />hereby certify under penalty of perjury that the source for the varld- <br />tion was not due to unauthorized (leak) release. (yes in Colum <br />the Inventory Reconciliation Sheet), 13 of <br />List date, tank #, and amount for all variations that exceeded <br />the allowable limits. <br />Date Tank # <br />Amount <br />i. �oIiI - ;--+ 6_101 s <br />2. <br />3. <br />4. 1 1 I T -S 601161-6 <br />5. 1�1 1 lQ C- 11,ri5 <br />Additional dates/amounts shall be continued on a separate sheet <br />paper and attached. <br />If the source of the variation which exceeded allowable limits was <br />due to a leak, the incident shall be reported to San Joaquin Local <br />Health District; Environmental Health Division, within twenty-four <br />(24) hours and an unauthorized release report submitted. <br />The quarterly summary report shall be submitted within fifteen (15) days <br />Of the end of each quarter. <br />Quarter 1 - January ---------- >March <br />Quarter 2 - April ------------ >June <br />Quarter 3 - July ------------- >September <br />Quarter 4 - October ---------- >December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 468-3420 <br />Eff 23 019 10/86 <br />