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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />FacLUty Name: <br />Facility Wdress: <br />Telephone: <br />Person F ing <br />Report " <br />0� _t <br />ENVIRG1;EtiTta► <br />ElI 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 as 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 <br />f Amount <br />3. <br />4. <br />_3c� <br />Additional dates/amouats <br />shall be continued <br />oo 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 licalcti <br />within 24 hours and an unauthorized release report submitted. <br />The Quarterly summ,ry report shall be submitted within 15 days of the end of cacti <br />Quarter. <br />Quarter I - January --> March <br />Qvartcr 2 - April --> June <br />Quarter ) - July --> septcmhr.r , <br />Quarter 4 - October --> Gecember <br />Send to: SAN JOAQU I N 1.0CAI, HHALI-Is DISTRICT <br />1601 E. llazc• 1 t cin . P . 0 . lacy 2001) <br />Stockton. CA 95201 466-6761 <br />T 40 10/86 0 <br />0 <br />