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INVENTORY RECONCILIATION REMCENLJ <br /> QUARTERLY SUMMARY REPORT FORM JAN 04 X2"03 <br /> Facility Name: `— J <br /> G C ./✓ Ltfc-- Tank ISize <br /> Product <br /> Facility Address: 121 <br /> _ 11VI Al " 9 <br /> Telephone : 'LEO 7 <br /> Person Filing <br /> Report A/1_ <br /> 1[ 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 B of the Inventory Reconciliation Sheet) <br /> 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) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, aad 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 al-Lovable Limits was due to <br /> leak the incident shall be reported to S ,J . L. H . D . Environmental Health <br /> wiChin 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 --> March <br /> Q+sarter 2 - April --> June <br /> Quarter 3 - July ---) Septemhitr <br /> Quarter 4 - Octobcr --> December <br /> Send to: SAN JOAQUIN WCAL HEALTH DISTRICT <br /> 160L 11 . Haze 1 t (in , P .O . 1j()x 2()()i) <br /> CT 140 I(?/ tib 5Locktan , CA 05201 466-67b1 <br />