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NVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name : <br /> Tank # Size Product <br /> Facility Address : q55 W. Gt'c ►Ti,ntc Iv 2� <br /> b CW 0 AJ <br /> `Telephone : y. 3'5 - r)a5q <br /> Person Firling A3 A <br /> Report : )� ,L P;= <br /> [ ] I Hereby certify under penalty of perjury that all inventory <br /> variations for the above mentioned facility were within the allowable <br /> limits for this quarter. (No in Column 13 of the Inventory , <br /> / Reconciliation Sheet ) . <br /> �►X Inventory variations exceeded the allowable limits for this quarter. <br /> I hereby certify under penalty of perjury that the source for the <br /> variation was not due to an unauthorized ( leaks) release. ( Yes in <br /> Column 13 of the Inventory Reconciliation Sheet ) . <br /> List date, tanks # , and amount for all variations that exceeded the <br /> allowable limits . <br /> Date Tank # Amount <br /> 2 . �r�/�'�.- -. ... <br /> 3 . <br /> 4 . ' -— I, <br /> 5 . <br /> Additional dates/amounts shall be continued on :a:: sep'ara'te', sheet of <br /> paper and attached . <br /> If the source of the variation which exceeded allowable limits was due <br /> to 2 leak the incident shall be reported to S.J.L.H. D. Environmental <br /> Health within 24 hours and an unauthorized release report submitted . <br /> The quarterly summary report shall be submitted within 15 days of the <br /> end of each quarter. <br /> Quarter 1 - January --> March <br /> Quarter 2 - April ---> June �� <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December - <br /> Send to : SAN JOAQUIN LOCAL HEALTH DISTRICTr, ' '�' <br /> a <br /> 1601 E. Hazelton, P. 0. Box 2009 � - -' ��• - :.Y',a' �, <br /> Stockton , CA 95201 466-6781 <br /> T 40 10/86 <br />