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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Home: �0 . eAeA hiq?-4 -#-I Tank i Sire Product <br /> S t4 o re!n <br /> Facility Address: �,,o-g 7 r xr R d 066 <br /> Telephone : ;? 4y•? -- <br /> k <br /> Person Filing <br /> Report i <br /> L hereby certify under penalty of perjury .that all inventor-y variations for <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (Flo in Column 13of the Inventory Reconciliation Sheet) <br /> QInventory variations cxcceded' the allowable limits forthis quarter. Y <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to as unauthorised (leak) release. (Yes in: Column 13"of Che <br /> Inventory Reconciliation. Sheet) <br /> List date. tank f, and amount for all, variations that exceeded the <br /> allowable limits. <br /> Date Tank E Amountt najl <br /> EW <br /> t. <br /> 2. OCT 9 ..� <br /> a_ .ENVIRONMENTAL HEALTH <br /> PCRMIT/SERVICES <br /> 4. <br /> 5_ <br /> Additional dates/amouata: shall be contioucd on a separate sheet of <br /> paper and attached. <br /> If the source of the variation, vhich. exceeded allowable limits was due to <br /> a leak the incident shall be reported to S •,J Z, • H • p, Environmental llcalth <br /> IE within 24 hours and an unauthorized release 'report submitted. <br /> i <br /> E The quarterly summary rrport shall be Rubmitted Within 15 days of the end of each <br /> E guar Cc7 r. <br /> Quarter I - January --) March <br /> Qlartcr 2 - April --> Jung <br /> Quarter 3 - July --> Septembor. <br /> Quarter 4 - OCCobCr .,--> N-Cember <br /> I <br /> scud co: SAN JOAQUIN I. CA1. HEALTH UISTKICT <br /> 160t E . Haze 1 I on . P -0 - Itox 2009 <br /> Stockton , CA 1)5201 461, -6161 <br /> rc;I• 40 10/86 <br />