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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM V <br /> DEC 3 01988 <br /> Facility Nage: Iraid QJ ( Tank / SizeNVQ EALTH <br /> ES <br /> facility Address: r- <br /> D <br /> Telephone : ISlq <br /> Person Filing Q// { <br /> Report Cwnd� �/ orntiJ <br /> 0 1 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 colu® 13of the Inventory Reconciliation Sheet) <br /> E] 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 f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank / Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amouats 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 Health <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly so, ry report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter 1 - January --) March <br /> Q•iarter 2 - April --> June r� <br /> Quarter 7 - July --> is ptember <br /> Q�.arter 4 - October --> Uccemher 1% <br /> Send co: SAN JOAQU I N LOCAL HEALTH II I S I P I C I' <br /> 1 601 l: . Haze I 1 nn . 1' Il H x. 7nW1 <br /> Stockton . CA 9'J201 466 - 01bl <br /> (:'I 1.0 M/ 80 Nh <br />