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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: Lod.t.. M'ekAC)Fr(M1 ge sp,rz <br />Facility Address: 7S tar �tcto�f�Y-K-- <br />c c� <br />Telephone: (foci) <br />Person Filin <br />L:,: <br />Report <br />j 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. (Ho in Column 13 of the Inventory Reconciliation Sheet) <br />QInventory variations exceeded the allowable limits for this quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />vas not due to an unauthorized (leak) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) _ <br />List date, tank It and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank I Amount <br />1. ..J <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 />Quarter I - January --> March <br />Quarter 1 - April --> Julie <br />Quarter 3 - July --> September' <br />Quarter 4 - October --> December <br />Send to: <br />SAN JOAQUIN „UCAI. HEAL'1'li UIS'I'KIC'1' / { � ` 187 <br />1601 E. l;azc 1 C cin , P.O. Box 2009 <br />Stockton, CA 95201 466-67b1 `nAQUINCOL12"% <br />I' 40 10/86 COWRO! [: <br />