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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Eaeil ty Name= 1. , ,'/�'ri; C Tank 0 Size Product <br /> ] ,7 .. a c' <br /> 1FACMty Address: IZ6 <br /> `% ✓J t t Vii[Li;> c • c' d 5 3 f <br /> Telephone : - '-/ <br /> Person Filing <br /> Report <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 /> gaarter. (No in Column 13 of the inventory Reconciliation Sheet) <br /> El 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 i, and amount for all variations that exceeded the <br /> allowable limits. <br /> rea <br /> Date Tank Amount <br /> 2. ,� �n <br /> 3. 3A� Q <br /> 4. ENVIR©MENSAL HEALTH <br /> /SERVICES <br /> 5.3. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> tf the source of the variation which. exceeded allowable limits was due to <br /> a leak the incident shall be reported to S „3 _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 1 - January --> N.-irch <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 -- October --) [lkcember �/ �2r/ <br /> Send co: SAN JOAQUIN LOCAL HEALTH UIS'1'ItIC"1' <br /> 1601 E . Haze ! I (m , P .O . ox 2009 <br /> Stockton , CA 95201 466 -67hl <br /> 40 10/ H6 <br />