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----_-_ -..- INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM \ <br /> - - Facility Name: ry Tank Size. JProduct <br /> /Zoo. <br /> Facility;Address: �j� j �i�Ti�il�- Z �gp, iA�L/NE <br /> Telephone : -20'7 -9 3�-0-770 <br /> Person Filing - <br /> Report Z� <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 Column 13 of 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) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #,. and- amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank # Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <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 /> fi <br /> i i i - January --) March �Y <br /> ;,�r I - April --> June <br /> Quarter 3 - July --) Scptembt!r <br /> Quarter 4 - October --> December <br /> Send co: SAN JOAQUIN I.00AL HEALTIi UISTRIC, <br /> 1601 K. Hazelton . P .O . Box 2009 <br /> Stockton , CA 95201 466-6761 <br /> LJGT 40 10/86 <br />