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INVENTORY RECONCILIA`1'I�N <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: �; y a � _ ,; <br /> Tank #( Size Product <br /> Facility Address : :r, .:.�, . ;• iCzw# tom- . <br /> Telephone: ^,. .i <br /> Person Filing <br /> Report: -71 <br /> I hereby certify under penalty of perjury that -all inventory variations <br /> for the above mentioned facility were within the allowable limits for <br /> this quarter . (No in Column 13 of the Inventory Reconciliation Sheet. ) <br /> Inventory variations exceeded the allowable limits for this quarter.❑ I hereby certify under penalty of perjury that the source for the varia- <br /> tion was not due to unauthorized ( leak) release. (Yes in Column 13 of <br /> the Inventory Reconciliation Sheet) . <br /> List date, tank It , and amount for all variations that exceeded <br /> the allowable limits . <br /> Date Tank # Amount <br /> 1 . --�--` <br /> 2 . <br /> 3 . <br /> 4 . ( / <br /> 5 . <br /> Additional dates/amounts_-s-hal1 b' e continued on a separate sheet <br /> paper and attached. <br /> If the source of the variation which exceeded allowable limits was <br /> due to a leak, the incident shall be reported to San Joaquin Local <br /> Health District; Environmental Health Division, within twenty-four <br /> ( 24 ) hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within fifteen ( 15 ) days <br /> of the end of each quarter. <br /> Quarter 1 - January---------->March lq?r. l5 <br /> Quarter 2 - April------------>June mil 15 <br /> Quarter 3 - July------------->September Cie f /5 <br /> Quarter 4 - October---------->December -:T cx,,1 15 <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton, P.O. Box 2009 <br /> Stockton, CA 95201 468-3420 <br /> LII 23 019 10/86 <br />