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INVENTORY RECOttCILIATION <br /> QUARTERLY SUMMARY REPORT FORN <br /> Facility tiara. <br /> _ Tank i <br /> Size 'roduct <br /> Fac: ity Address: j <br /> CZ <br /> Telephone : � <br /> Person .Fi g <br /> Report <br /> L hereby certify underil sna <br /> p y Of perjury that all invcnto ariat IV <br /> the :bows c�entioned facility were within the allowable Lim i or <br /> quarter. (No in Column 13of the Inventory Reconcilia ® h <br /> L HEALTH <br /> PERMIT/SERVICES <br /> Q 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) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> Last date, tack i, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank Amount <br /> 2- <br /> 3. <br /> 4. <br /> 5. <br /> Additional dace:/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 . T, H . D Environmental liealth <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall btr submi [tcd withi <br /> quarter , n IS d,mys of the end of rash <br /> Quarter i - January --) Harch <br /> Q+Jartcc 2 April __, acrne- <br /> ur_..._4ar[er 3 - July <br /> Q"acCcc e - c o er --? 1 _Ccmbcc <br /> Jen`' to: SAN .JOAQUIN LOCAL 11LAL1'11 UISTRIC1' <br /> 1601 F . Hazelton , P .O . Box 2009 <br /> UCT 40 10/86 Stockton , CA 95201 466-6781 <br />