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INVENTORY RECONCILIATION ;-tt"w ,,,._ <br /> QUARTERLY SUMMARY REPORT FORM PFf' "l7 'E'RMT <br /> Facility Name: -7 <br /> /amu iNrr,� Tank I ~ Size Y 'Product <br /> Facility Address: �/ �� its_• ��w✓ <br /> Z 1c <br /> Te lephone : .._, 10 <br /> Person Filing` ''' <br /> Report <br /> L herebycertify y under penalty of perjury that all inventory variations for <br /> the above n+eationed facility were within the allowable limits for this <br /> quarter. (!Io in Column I3 of the Inventory Reconciliation Sheet) <br /> ElLaventory variations exceeded the allowable Limits for this quarter. Z <br /> hereby certify under penalty of perjury that the source for the variation <br /> vas not due to an unauthorized (leak) release. (Yea is Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable lignite. <br /> Date Tank I Amount <br /> 1. <br /> 3. <br /> 4_ <br /> 5. <br /> Additional dates/=mounts shall be continued on a separate sheet of <br /> Paper and attached. <br /> If the source of the variation vhich. exceeded al-lowable limits was due [o <br /> a leek the incident shall be reported to S .J . L. H . D . Environmental Health <br /> within Z4 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be subcnittcd within 15 days of the end of each <br /> quarter. <br /> Quarter f - January -- > March <br /> Q11arter 2 - April --) June <br /> Quarter 3 - July --> Scptcmh(-r <br /> Quarter 4 - October --) 1}cecmGer <br /> Send to: SAN JOAQU IN LOCAL HEALTH DISTRICT <br /> 160L E. Haze 1 t rslt , p . O . 1i()x <br /> 4(1 10/ t36 Stockton , CA 95201 466 -67/81 <br />:T <br />