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INVENTORY RECONCILIATION <br /> � 1QUARTERLY <br /> .�-SUMMARY REPORT FORM <br /> Facility Name: _�/ 7 fTa �1 fo•' �Jf Tank I size Product <br /> Facility Address: _/1"g—e? 6- ,007�Z,rnc <br /> v.- A U'T r/Jif�3 <br /> Telephone : ?p%- 7y1-lel y f <br /> Person Fili / <br /> Report 4' yf!2 �•,,., � <br /> ' f [ 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 /> 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 /> Dale Tank R Amount O (gal �U�\ <br /> 2. <br /> 3. E^rv� ME P�L H%CEE LSH <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 ..1 . 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 /> QiaC[cr 2 - April --> June <br /> to <br /> ✓Quarter 1 - July --> %eptcmber 0 <br /> Q%sarter 4 - October --> december l% <br /> Send to: SAN J OAQUIN LOCAL HEATAli DIS'IIICT <br /> 1001 C . Hazo l t (ut , PA) It 7OWl <br /> Stockton . CA 9'-)201 /.(.(. - 0181 <br /> J(:'1 40 HUM)/ Ht) <br />