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! ! ! <br />FaciLity Name: <br />1 0 <br />46-11 I. / <br />I l s167 <br />Telephone:,UL/ <br />Person -41 ZZ <br />! • I` <br />a i`. <br />I hereby cartify under penalty of perjury that all inventory variations for <br />thy: above mentioned facility were within the allowable limits for this <br />quarter. (No in Column 11 of the Inventory Reconciliation Sheet) <br />Inventory variations exceeded the allowable limits for this quarter. I <br />hereby certify under pecalty.of perjury that the source for the variation <br />was not due to in unauthorised (leak) release. (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 />). <br />4. <br />5. <br />Additional dates/amounts shall be continued on a separate aheet of <br />paper and attached. <br />If the source of the variation which. exceeded at -lovable limits was due to <br />a teak the incident shall be reported to S.J.L.N.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 1 - January --) March �� 9 <br />Quarter 2 - Aprit --> June <br />Quarter , July --> Septemhtar </ <br />Quarter 4 k:-001 Oc t obe r --> Gc-c"bcr t® <br />Send to: SAN JOAQUIN LOCAL NEAL11i UIS'1'l icr <br />1601 E. 1laze 1 t cat . P.O. Box 2009 <br />• Stockton • CA 95201 466-6761 <br />u:T 40 10/86 <br />