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INVENTORY <br />RECONCILIATION ■ <br />QUARTERLY <br />!i 1' REPORT <br />!ii , <br />Facility Name: e <br />Facility Address: <br />y <br />C <br />❑ L 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 />❑ Luveatory variations exceeded the allowable Limits for this quarter. t <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to an unauthorized (leak) releiae. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank /, and amount for all variations Chat exceeded the <br />allowable limits. <br />Date Tank P Amount <br />�4P <br />3. „a <br />4. <br />i <br />Additional dates/amouats shall be continued on a separate sheet of <br />paper 2nd 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 L.H.D. Environmental licalth <br />within 24 hours and an unauthorized release report submiCted. <br />The quarterly summary report shall be Rubmitced within 15 days of the end of each <br />quarOr! r. <br />Quarter I - January --> March <br />Quarter 2 - April --> Juni <br />Quarter 3 - July --) Septcmhcr <br />QuaeCcr 4 - October --> Dece•mhcr <br />Send co: SAN JOAQU IN 1.0CA1. HEALTIi DISTRICT <br />1601 I.. Haze 1 i oil . V.0. KIDx 2009 <br />Stockton, CA 95201 466-67b1 <br />OCT 40 10/86 <br />