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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: / Tank f Sic= Product <br /> 0 ' <br /> F+eility<Addcess: Al', W( L /L'W(+ GI � t <br /> �6uC <br /> STc�Cl- 'jLA/ (A �ISo2 <br /> Telephone : -- o C <br /> Person Filing _ <br /> Report <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 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 unauthorised (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sfieec) <br /> List date, tack /, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank / Amouot <br /> 1. jJ <br /> 2. <br /> 3. JAN 0 2 1991 <br /> 4, 1- .VIRONMENTAL HEALTM <br /> S. <br /> PERMIT/SERVICES <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 Uealth <br /> wLthin 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 /> Quarter 2 - April --> June <br /> Quarter(D - July --> Septemhcr <br /> Quarter 4 - October --) December <br /> Send co: SAN JOAQUIN LOCAL HEAL1'li DISTRICT <br /> 1601 E. liaze l lon , 11 .0 . Iiox 2009 <br /> Stockton . CA 95201 466-6761 <br /> EH 23 019 10/86 <br />