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&VENTORY RECONCILIATION <br />Al � QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Facility Address§ADr'LP "'iT7 (K'PON <br />64,71 iT.DDOCK PLACE <br />INTEp <br />Telephone: LODr ('et:c 95240 <br />Person Filing (209) 334.0975 <br />Report <br />4. <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 Colum 13 of the Inventory Reconciliation Sheet) <br />Q Inventory variations exceeded the allowable limits for this quarter. 41 0 1989 <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to an unauthorized ( leak) re lease. (Yes in Column 13 of." NMENTAL HEIsFpvr, <br />Inventory <br />Inventory Reconciliation Sheet) <br />List date, tank #, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank # Amount <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 Health <br />within 24 hours and an unauthorized 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 - April --> June <br />Quarter 3 - July --> September <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />UGT 40 10/86 <br />