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N <br /> a• <br /> r, .. <br /> 1% <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: ii9Uli��s.tJf7irQ1 Tank I <br /> Size Product <br /> Facility -Address: <br /> Telephone : _ �7 �,� <br /> Person Filing <br /> Report <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> 'he above mentioned facility were within the allowable limits for this <br /> quarter. (No is Column 13of 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 as unauthorized (leak) release. (Yes in Column 13 of the <br /> Iaveatory Reconciliation Sheet) <br /> List date, tank /, and amount for all variations that exceeded the <br /> allowable lianits. <br /> Date Tank f Amount <br /> I. <br /> 1. <br /> 3. <br /> 4. <br /> S. <br /> Additional dates/amounts &hall be continued on a separate sheet of <br /> paper and attached. <br /> i <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 Health <br /> Within 24 hours and an unauchorized 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 3 - July --) Scptemhr.r <br /> Q�iarCcr 4 - October __) -Rj•ci mhcr i <br /> Send to: SAN JOAQUIN UWAI, HEAL1'li DISTRICT <br /> 1601 E . Haze 1 t (vn , p . U . lic>x ZOO') <br /> 40 l 0/ N6 Stockton , CA `/5201 460 -67bl <br /> Jt:T <br />