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� t <br /> INVENTORY RECONCILIATIONS _. <br /> QUARTERLY SUMMARY REPORT FORM <br /> ,.,/� 'LTH <br /> Facility Name: V4a�+j/1 rO4Q Tank # size Product <br /> 1 / D c9 <br /> Facility Address: / �1• <br /> 1X9d A--09 (fa r <br /> Telephone : 0�o2- CQ91:{~ 3 Loi <br /> Person Fil�Loo <br /> ng / <br /> Report /IV J- We/r/06KJ <br /> Scotch"7664"post-it"Routing-Request Pad <br /> Q I hereby certify under penalty of i <br /> Please ROUTING _ REQUEST <br /> the above mentioned facility were , <br /> quarter. (No in Golu=a 13 of the I El READ To <br /> 014ANDLE <br /> QInventory variations exceeded the and APPROVE 7 <br /> hereby certify under penalty of ps ; - <br /> was not due to an unauthorized (Is FORWARD <br /> Inventory Reconciliation Sheet) RETURN , <br /> KEEP OR DISCARD <br /> List date, tank t, and amou REVIEW WITH ME <br /> allowable limits_ <br /> Date <br /> Date Tank 41 <br /> r <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.H . D . Environmental sea1th <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly suawn-ary report shalt be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January March <br /> Quarter 2 - April --> .dune <br /> Quarter 3 -- July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH D1STRICT <br /> 1601 E . Haze 3 t cin , P .O . Box 2009 <br /> Stockton , CA 95201 466-6751 <br /> UGT 40 10186 <br />