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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility, Name; Tank <br /> Size Product <br /> !a c i 1 i.ty Add re.s: �D/ �:r w er6•e IVA <br /> Telephone : Al (4 rZa <br /> Person Filing <br /> Report _ ���.l�o-a n �/ ���.v1EEEEEI <br /> ErI hereby certifyunder <br /> penalty of perjury that all inventory variations for <br /> 'be above meationed facility were within the allowable limits for this <br /> quarter. (No is Column13 of the Inventory Reconciliation Sheet) <br /> ElInventory 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 as unauthorized (leak) release. (Yes in Column13 of the <br /> Inventory Reconciliatio(i Sheec) <br /> List date, tank fc and amount for all variations that exceeded the <br /> allowable lis,its. <br /> Date Tank E A=ouat <br /> I. <br /> 2. <br /> 3. <br /> 4_ <br /> 5. <br /> Addittooal dates/amounts &hall 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 Veatch <br /> Within 24 hours and an unauthorized release report submitted_ <br /> The quarterly summary report shall be Rubmicted within IS days of the end of each <br /> quarccr_ <br /> Quarter I - Jaouary --) March <br /> Q'larcer 2 - A Cil --) Jure_.. -0 <br /> ro1 <br /> Qua cr - July --> Scptemhrr� ! � Eh <br /> Q.actcr - <br /> 4 '`' <br /> October -> D�ci ml cr <br /> OCT d � 199 <br /> Send co: SAN ion<.�u I ry t.l�c:ni. HEALTH u l s l It t c r ENVIRONMENTAL HEALTH <br /> 1601 f: . !!aze 1 t i,i, , f' . o . 1j()x lrl()') PERMIT/SERVICES <br /> Stockcon . CA 95101 466 -67b1 <br /> T 140 10/ 86 <br />