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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM E'�`PERMIT!S `= 1'E��TH <br /> Q I'ER.MI?!SERVICES ' <br /> FaeiLitae: Tank ! $mMAI Product <br /> r <br /> lacility,Add[ese: <br /> Telephone : � <br /> Person Fili -1=�-1--� <br /> Report <br /> t=1 • 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 /> 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 an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Street) <br /> List date, tank /, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank / Amount <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts ahall 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 /> wiChin 24 hours and an unauthorized release report submitted. <br /> The quarterly summary r�POrt-ahall.b_e_ nubmitted within 15 days of the end of each <br /> quarter. —" --� <br /> Quarter <br /> �_\ January --) H,ar-h <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --) Scptcmh(!r <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN U)CAL HEALTH DISTRICT <br /> 1601 E. Hazelton , 11 .0 . Box 2009 <br /> Stockton , CA 95.201 466-6761 <br /> EH 23 019 10/86 <br />