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N <br /> • <br /> INVENTORY RECONCILIATION NOV 7 r9n <br /> QUARTERLY SUMMARY REPORT FORM <br /> ENW, <br /> Facility Name : <br /> Tank # Size Product <br /> Facility Address : q�2 ? / 000 a <br /> 2 <br /> oc r.2L 0 0 <br /> Telephone : <br /> Person Filing ' <br /> Report : <br /> C,�IHereby certify under penalty of perjury that all inventory <br /> variations for the above mentioned facility were within the allowable <br /> limits for this quarter. (No in Column 13 of the Inventory <br /> Reconciliation Sheet ) . <br /> Inventory variations exceeded the allowable limits for this quarter. <br /> I hereby certify under penalty of perjury that the source for the <br /> variation was not due to an unauthorized (leak) release. (Yes in <br /> Column 13 of the 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 /> 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 <br /> 0 T <br /> to a leak the incident shall be reported 4-V S.J. U.N.D. Environmental <br /> Health within 24---hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within 15 days of the <br /> end of each quarter. <br /> Quarter 1 - January March y1100 <br /> Quarter 2 - Ap <br /> June <br /> � <br /> September2cmr <br /> 4Zdarter 3 July <br /> Quart e�r �co Uer e er <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton, P. 0. Box 2009 <br /> Stockton, CA 95201 466-6781 <br /> T 40 lo/86 <br />