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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility !tame: �/�/(�� Tank i Size Product <br /> Facility Address: 3 <br /> Al,�!/ r <br /> Telephone : <br /> Person Filing <br /> Report <br /> I' hereby certifyunder penalty p lty of perjury that all inventory variations For <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (mo in Columna 13 of the inventory Reconciliation Sheet) <br /> Elinventory variations exceeded the allowable limits for this quarter. Y <br /> hereby certify under penalty of perjury that the source for the variation <br /> vas Got due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for all variations that exceeded the <br /> allowable limits_ <br /> Date Tank I Amount M <br /> a1 <br /> 2. OCT 1 1 1990 <br /> 3. <br /> 4. <br /> S. <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 duct to <br /> a leak the incident shall be reported to S .J L . H . D . Environmental Health <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be rubmittcd within 15 days of the end of each <br /> quarter. <br /> Quarter I _ January --) March <br /> Quarter Z - April --> June <br /> Quarter 3 - July --} Septem6cr <br /> Quartcr 4 - October --) DLce.mber <br /> Send to: SAN .JOAQUIN LOCAL HEA1.11i DISTIiICT <br /> 160 1 F: . Haze I t iin , l' . 0 . ji()x 1()()g <br /> SLockLon , CA 95201 466 -67b1 <br />!ICT 40 10/ 86 <br />