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5 <br />INVENTORY RECONCILI-ATION AP <br />QUARTERLY SUMMARY REPORT FORM EDiviRo.- t - <br />1ER�'rlt�'� �'�✓t�r�LT� <br />Faeiiity Name:tj <br />Faeilitr,Address: Z4/,'(JD `%�� �m 10. <br />Telephone :-�i <br />Person Filing �' -,-2 <br />Report <br />NEVA FA WA FAVW� <br />0 1 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) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank f, and asount for all variations that exceeded the <br />allowable limits_ <br />Date Tank E <br />Amount <br />/ D5 <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 ticaltti <br />within 24 hours and an unauthorized release report submitted. <br />The Quarterly summary report shall be submitted within IS days of the end of cacti <br />Quarter. <br />Quarter I <br />- January <br />--) <br />March <br />QvarCer 2 <br />- April <br />--> <br />June <br />Quarter 3 <br />- July <br />--) <br />Septemhr.r <br />Quarter 6 <br />- October <br />--> <br />(kcember <br />Send to: SAN JOAQU I N WCAL Hl;AL11i DISTRICT <br />1601 K. H azc• I t cin , P . O . Box 2009 <br />Sckton . CA 45201 466-6761 <br />T 40 10/86 <br />