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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Tank at! Size Product <br /> Facility Address: <br /> .. �rr. � •> <br /> Telephone : . <br /> Person Filing <br /> Report <br /> f <br /> L hereby certify under pc:alty of perjury that ala invento v <br /> the above mentioned facility were within the allowable 1y f <br /> quarter. (No in Column 13of the Inventor Reconciliatio <br /> _ <br /> tiytb <br /> J AN 15 1992 <br /> El Inventory variations exceeded the allowable limits forE6WtiQM W;AL JiEALTH <br /> hereby certify under penalty of perjury that the source fiVMT4iW i�abs <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 f Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and_ attached. <br /> i <br /> If the source of the variation which. exceeded at-lovable 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 summary report shall be Rubmitted vithin 15 days of the end of each <br /> Quarter. <br /> Quarter I - January --) March <br /> Q,iarter 2 - April --> June <br /> Quarter 3 - July --> Septemh(!r <br /> 1 Quarter 4 - October --> lk'cember <br /> Send to: SAN JOAQU IN LOCAL HEALTH DISTRICT <br /> 160L E . Hazelton . P . O . Box 2000 <br /> Stockton , CA 95201 466-67bl <br /> LJGT 40 LO/86 <br />