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n <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Fac i Li ty Name: lxwekml -2-�- <br /> eTank SizeProduct <br /> Facility Address: <br /> Telephone . �, �� � °�� ,�- �.t r� <br /> Person Filing <br /> Report <br /> k L hereby certify under penalty of perjury that all inventory variations for <br /> the above meationed facility were within the allowable limits for this <br /> quarter. (No in Colu"a 13 41 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 /> vas 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 /> allowable limits. <br /> Date Tank I Amount <br /> 1. <br /> 2. <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 due to <br /> a leak the incident shall be reported to S •J , I_,, H . p , Environmental Health <br /> Within 24 hours and an unauthorized release resort 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 /> Quarter 2 - April --) June <br /> Quarter 3 - July <br /> Qt,arter 4 - October --) [74--cember <br /> Send to: SAN JOAQUIN 1,0CAL Hl A1_1'li DI:iTKICT <br /> 160 1 F . Haze 1 i (r[) , I' . U . 1�ox 2009 <br /> l_ oc1SLon , CA 95201 1466 -67b1 <br /> L1(;T 140 10/ 80 <br />