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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORK <br /> rill <br /> Facility Name: ' r rvff�l '�. ,✓C Tank <br /> "Sia' + Product <br /> FAcility Address: ) ������ Esc' <br /> 700 /�. <br /> r - <br /> Telephone : <br /> Person Filing <br /> Report <br /> 13/I herebycertify y and er 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 /> ElInventory 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 Columa13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank # Amount <br /> 3. <br /> 4. <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 0 L. p Environmental Health <br /> wtithin 24 hours and an unauthorized release report submitted. <br /> The quarterly sumcmary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) Harch <br /> Quarter 2 - April --> June <br /> Quarter ) - July --) September <br /> Quarter 4 - Octobcr --) Ckcember <br /> Send to: SAN JOAQUI.N I-OCAL HEALTH DISTRICT <br /> 160L 1:1 . Haze 1 t ,,i1 , p . o . 11Ox 2()()g <br /> 5Lockton , CA 95201 466 -67bl <br /> c.: )' 140 10/ 86 <br />