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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: QU..I < Srb125 Tank I <br /> Size Product <br /> Fac. ity Address: l5' j A/� �T o OD6 EG <br /> a L <br /> -Telephone : may_ <br /> Person Filing <br /> Reporr- <br /> L hereby certify under penalty of perjurythat all inventory <br /> ti <br /> the above mentioned facility were within the allowable limsvfor athiss for <br /> quarter. (No in Column 13of 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 Col.caaa 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 Amount <br /> 1_ <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, to <br /> a Leak the incident shall be reported to S .J .L. H. D. Environmental Health <br /> within 24 bouts and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within <br /> quarter. OS days ok the end of each <br /> Quarte I - January March <br /> Tarter - April --) ,June <br /> Quarter 3 - July --> September 10 <br /> Qt,arter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton , I1 .0 . Box 2009 <br /> 11CT 40 10/86 Stockton, CA 95201 466-6781 <br />