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a <br />w ob <br />qINVENTORY RECONCILIATION <br />UARTERLY SUMMARY REPORT FORM <br />a{ U L 1 c 1988 <br />FaRO <br />ENV1R�AI �ea L4 <br />Fsci lPa/�Td�lSERViC <br />cess. (j <br />Telephone: _ a - s <br />Person Filing <br />Report <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) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) _ <br />List date, tank i, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank f Amount <br />2. <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 at.lowable 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 --) Hirch <br />Quarter 2 - April --) June <br />Quarter 3 - July --> Septemhcr <br />Quarter 4 - October --) December <br />Send to: SAN JOAQUIN LOCAL. HEALTH DISTRICI' <br />1601 E. Ifaze 1 t o n , 1' . 0 . 1i()x 2009 <br />ll(;T 40 10/$6 Stockton, CA 05201 466_6781 <br />