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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM OCT 141987 <br /> Facility Name; _L [,/r� I JCTank # Si,ZeLNV i UM qtjH <br /> 7.7, c J <br /> Fac.iLity Address: c' r d <br /> Telephone - <br /> Person <br /> elephone :Person F i,,� Fi <br /> Repo C t �" �� C i 'I <br /> �a <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 /> ti <br /> Qlaaentory variations exceeded the allowable limits for this quarter. I <br /> l+creby certify under penalty of perjury that the source for the variation <br /> was not due to an unauthorized (Ltsk) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable Limits. <br /> Date Tank f 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 snd 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. H D. Environmental Health <br /> within 24 hours aad an unauthorized release report submitted. <br /> The quarterly summary report shall be Kubmitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --> Harch <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> Septcmh4-r <br /> Quarter 4 - October --> Ihcember <br /> Send to: SAN JOAQU IN 1,0CAL HEALTH DISTRICT <br /> 1601 E . Haze t ton , P .O . Box ' 2009 <br /> Stockton , -CA 95201 466-615l <br /> ;T 40 10/ 86 <br />