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INVENTORY RECONCILIATION <br /> SUMMARY RFORM �U <br /> QUARTERLY SU REPORT <br /> Facility Name: �//A wyy-' J'99 A"\- 'tank # Size Product <br /> ��^^�� '' // C� t,i 00A <br /> Facility Address: ��D tiJ- �(W� �� , � D D Cin L <br /> T 0 ����� U k, <br /> Telephone : 11 — 67 <br /> Person Filjng <br /> Report / /;A- -i C <br /> I 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 13of the Inventory Reconciliation Sheet) <br /> LJ <br /> I.Lucy variations exceeded the allowable limits for tb:.s quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank I, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> S. <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 lfr_alth <br /> Within 24 hours and an unauthorized ►elea report submitted. <br /> The quarterly summary report shall be submitted within 15 days of the end of each <br /> Quarter. <br /> Quarter January --) March <br /> Q+larter 2 - April --) June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --) (}rcember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160 1 E' . Haze I t (�n . 1' . 0 . hOx 2000 <br /> Stockton , CA 95201 460 -6781 <br /> U(;T 40 10/ 80 <br />