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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: �`k Ta I <br />Plc ity Address: r�+Z� /V, 7 - <br />Telephone: Telephone: <br />Person Filing <br />Report 114/Yl k /_,�� �a„-•, <br />Size Product <br />/'% jJdD ti <br />DOo C <br />5'0 o a fJi L <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 />QInventory 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 dater tank I, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank I Amount <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 IS days of the end of each <br />quarter. <br />Quarter I - January --J Harch <br />Quarter 2 - April --> June <br />- July --) September <br />Q,arter 4 - October --> December <br />Send to: <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />