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iNYENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: _ Tank I Size Product <br /> l <br /> Facility Address: OD <br /> Telephone : W9- 1551 <br /> Person F ling <br /> Report - <br /> QI 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. (Ho in Column 13 of the Inventocy Reconciliation Sheet) <br /> Inventory variations exceeded the allowable limits for this quarter. I <br /> hereby eercify under penalty of perjury that the source for the variation <br /> was not due to as unauthorized (leak) release. (Yes in Colum 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, taak f, aad aszounC for all variations that exceeded the <br /> allowable limits. <br /> Date Tank ak Amouat <br /> 1_ <br /> 2_ ppb <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/aasouatt &hall be continued on a separate sheet of <br /> paper and attached- <br /> If the source of the variation which. cxcecded allowable limits was due to <br /> a leak the incident shall be reported to S .J . L. H . D . Environmental Health <br /> WL ChL,n 24 hours aad an unauthorized release report submitted. <br /> The quarterly &uml ry report shall be FubmitCcd within 15 days of the cnd of each <br /> quarter. <br /> Qu:.rcer I - January --> March <br /> Q•sarccr 2 - April --> June <br /> Quarter 3 - July --) scpcemhr.r <br /> Quarter 4 - Octobcr --> [kc(•mbcr <br /> Scnd Co: SAN JOAQU IN 1,0CA1, HEAL1.H DISTRICT <br /> 160L E . P .O . Iic�x 2009 <br /> SIockr-on , CA 95201 466 -6761 <br /> llc;'I' 40 10/ 80 <br />