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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: ?0A S CocIC-*OL" 5 Tank t SizePro duct <br /> Facility Address: SO <br /> Telephone : e'7g8otao2 <br /> Person Filing <br /> Report A�cIL <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 /> quarter. (No in Column IJ of the Inventory Reconciliation Sheet) <br /> ElInventory 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 t, and amount for all variations that exceeded the <br /> allowable limits_ <br /> Date Tank I Amount fn� /,a�If-,aie •. 1 <br /> t� <br /> 2. <br /> J'J iV <br /> 4. \ ENVIRUWL!v(AL HLALTH <br /> 5. F,ERMIVSERVICES <br /> Additional dates/amounts shall he continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. eaceeded allowable limits was due to <br /> a leak the incident shall be reported to S .J . L. H . D . Environmental Ilcalth <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 ��X <br /> Quarter 2 - April --> June to <br /> Quarter 1 - July --) %eptember 0 <br /> Quarter 4 - October --> Ikecrmber 1% <br /> Send to: SAN JOAQUIN LOCAI, HEAL'fli DISTRICT <br /> 1601 E . Hazelton , I' . 0 Ru: 2111111 <br /> Stockton ; CA 95201 466 -67bl <br /> OCT 40 10/ 86 <br />