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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Facility Address: 3j 1`, Gert t-MArN <br />1-x"-, .co t\��40 <br />Telephone : �Ac,���; -t �� <br />Person Filing <br />Report;U{ 1k�Q Pry <br />Tank i <br />Size Product <br />wee <br />R <br />lu <br />arosr,.,� <br />tf <br />3T I— <br />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 />El 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 1, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank !E Amount 1.... '� ` ' <br />J <br />2. <br />3. <br />EN F`ER1J11T /SERVICES <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 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 15 days of the end of each <br />Quarter. <br />Quarter I - January --> March <br />iartcr - prl <br />arter - u -=7 Scptcmb,r <br />Q%jarter 4 - October --) DLcember <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 1:. Haze 1 <<►n , P.O. Box 2009 <br />Stockton, CA 95201 466-6181 <br />UGT 40 10/86 <br />