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INVENTORY RECONCILIATION JAN 17 <br /> QUARTERLY SUMMARY REPORT FORM L,,,„i,'ONlyiENIASHEALTH <br /> t , <br /> Facility Name: A1 I M,4 Tank f Size Product <br /> FacilityzAddress: <br /> . . , .iy ! <br /> Telephone : — <br /> Person Filin <br /> Report < <br /> �I hereby cert y under penalty of pecjury that all inventory variations for <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (No in Column 13 of the Loventory 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 Colu® 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations chat exceeded the <br /> allowable limits. <br /> Date Tank f Amount I , < <br /> 3. +o <br /> 4. ;\L9 Aid work DnJ rE�” <br /> 5. M&V�Tor JNESi <br /> 1�t'f OA IZ/7M�, <br /> Additional dates/amounts shall be contioued on a separate sheet of <br /> paper .and attached. <br /> It the source of the variation uhich. 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 2 - 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 . ROx 2009 <br /> Stockton , CA 95201 466-6761 <br /> EH 23 019 10/86 <br />