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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> h FacWty. Name: il,}��yp, <br /> •' - A— ej Onka <br /> Size Product <br /> A Facility Wdress: � � <br /> — � 4a7V `� <br /> i <br /> Telephone : Ct1-4 <br /> Person Ff�1tt� <br /> ReportIR( (�!� 1 ,-sj� �:.�--�►-vV I l,�'� - <br /> r - <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 /> . <br /> uarter _ <br /> 4 (No in Column l3 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 /> i. allowable limits. <br /> s <br /> Date ate <br /> `` Tank f Amount <br />�8 1. <br /> 2. <br /> 3. <br /> 4. <br /> S. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper snd attached. <br />!y' <br /> If the source of the variation which. exceeded allowable limits was due to <br /> At leak the incident shall be reported to $ .J .L.H . D. Environmental Health <br /> w 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 1 - January --> March <br /> Qlarter 2 - April --> June <br /> Quarter ) - July --> Scptemhc:r <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HRAL11i DISTRICT <br /> 1601 F.*. Haze 1 t o n , P .O . Ilex 2009 <br /> UCT 40 10/HG Stockton , CA 95201 466-6781 <br />. <br />