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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> F'aeaiity dame: /,e41611 n(% Tank # Site Product <br /> !ac£lity lLddress: /qf��, ____ l �G <br /> rz <br /> Telephone ; ± l r F . s__ 7 <br /> Person Filing 7d 7, <br /> Report <br /> I hereby certify under penalty of perjury that all inventory variat-ions for <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (No in Colus= 13 of the Loventory Reconciliation Sheet) <br /> UJ Lw4entory variations exceeded the allowable limits for this quarter. I <br /> hereby certify sender 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 i, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Aeoout3C <br /> z. APR V <br /> 3. E�►V1,gaM 06 198? <br /> 4. FFRMI�S"ALVlH�LrN <br /> 5. SES <br /> Additional datesjamouuts shall be continued on a separate sheat of <br /> paper and attached. <br /> If the source of the variation vhich. exceeded allowable limits was due to <br /> a leak the incident shal i be reported eco S .J .L.H . D . Environmental health <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 --> March <br /> Quarter 7 - April --> June <br /> Quarter 3 - July --> Scptemhr.r <br /> Quarter 4 - October --> lk'cember <br /> Send to: SAID JOAQUIN LOCAL HEALI-H DISTRICT <br /> 1601 E . Harc l t 44,' . k' .0 . Ilex 2009 <br /> SLockr.on , CA 95201 466-67bl <br /> 40 111146 <br />