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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Wacility Name : # ZC(532 <br /> Tank # Size Product <br /> Facility Address : Davtoo-k IU DOO 1 r <br /> Stcx ��tz�t� c A Z 10 ,OLD Yore l U - <br /> Telephone23 <br /> [U <br /> Person Filing <br /> Report : �idr�a. bacr�a <br /> [ ] I Hereby 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 /> [✓j 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 . � L <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 /> to a leak the incident shall be reported to S .J.L.H.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 <br /> Quarter 2 - April --> June 0 <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December JAN 61969 <br /> Send to : SAN JOAQUIN LOCAL HEALTH DISTRICT ENVIRONMENTAL HEALTH <br /> 1601 E. Hazelton, P. 0. Box 2009 PERMIT/SERVICES <br /> • Stockton, CA 95201 466-6781 <br /> T 40 10/86 <br />