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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Na,: M M I Tank / <br /> Size Product <br /> facility Address: _ f <br /> :;�-k- � <br /> Telephone : 1 (r41_22G� <br /> Person Filing_ <br /> Report <br /> l hereby certify under penalty of per that all inventory variations for <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (No in Column 13of the loveatory Reconciliation Sheet) <br /> ❑ laventory variations exceeded the allowable limits for this quarter. T <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to an uaauthoriced (leak) release. (Yes in Coluaat13 of the <br /> laveatory Reconciliation Sheet) <br /> List date, tank /, and amount for all variations that exceeded the <br /> allowable limica. <br /> Date Tank 0 Am uat <br /> 1. <br /> 2. <br /> 3. <br /> 6. <br /> 5. <br /> Additional dates/amounts shall be concioued on a separate sheet of <br /> Paper and attached. <br /> if the source of (tic variation which exceeded allowable limits vas duc to <br /> a leak the incident shall be reported to <br /> Within 24 hours and an unauthorized release report ubmitte�onmcntal Ileal(h <br /> The Quarterly summ147 report shall be sabmit(cd within 15 days of the end of each <br /> quarter. <br /> Quarter 1 - January <br /> Q•iart,:r 2 - April --> Jou• <br /> Quartu:r )_- July __) Septemt <br /> Q,,a r to 4 - octobcr --) O,: <br /> comber <br /> Send to: SAN JOAQ(llry LUCAI, HEAL-I-li I)IS'CItIC'1' <br /> 1 601 li . I!azt I I nn • I' . O Itn.x 20(19 <br /> Stockton • CA 95201 4GG -G1bl <br /> 40 10/86 <br />