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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Address: _,�qo A/- l��,,q �s / <br />`4E -c A 533 <br />Telephone: <br />Person F ing <br />Report <br />. ...r I V <br />E� <br />4-j <br />APR 17 <br />} �"y �itd1 d B" 1991 <br />l INFt���ON ,7rti HT..,e`4. �_.. <br />de, <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) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank tv and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank # Amount <br />2. <br />= `� l 1 Ci (v+ <br />3. 3 <br />4. <br />• e <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 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 DISTRICT <br />1601 E. Hazelton, 1'.0. Box 2009 <br />Stockton, CA 95201. 466-6781 <br />UGT 40 10/86 <br />s <br />,>t <br />