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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: ROTO ROOTER Tank Size Product <br /> 1 10 . 000 UNLEADED <br /> Facility Address: 3480 E. CARPENTER RD. 2 1 . 000 DIESEL <br /> §TOCKTON <br /> Telephone: 465-2616 <br /> Person Filing <br /> Report: TONY VALENZUELA <br /> I hereby certify under penalty of perjury that all inventory <br /> variations for the above mentioned facility were within the <br /> allowable limits for this quarter. (No in column 13 of the <br /> Inventory Reconciliation Sheet. ) <br /> Inventory variations exceeded the allowable limits for this <br /> quarter. I hereby certify under penalty of perjury that the <br /> source for the variation was not due to authorized (leak) <br /> release. (Yes in Column 13 of the Inventory Reconciliation <br /> Sheet) . <br /> List date, tank #, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Date Tank Amount Reason <br /> t t) 1. 1-22-91 1 -DEI,TVFRV <br /> rn ¢(> /l/lec.4f. <br /> C752 . 1-23-91 1 22 GAT. — <br /> W <br /> !/c�roc <br /> c� U <br /> �Ir� fy Wy 3 . 2-19-91 1 23 (iAr._ <br /> L Z~ <br /> C Q� 4 . 1-19-91 2 5 GAT.. <br /> 5 . 3-25-91 2 2 GAT- <br /> 4 <br /> Additional dateslamourts shall be continued on a separate <br /> sheet of paper and attached. <br /> If the source of the variation which exceeded allowable limits <br /> was due to a leak, the incident shall be reported to Public <br /> Health Services of Sas: Joaquin County Environmental Health <br /> Division, within twenty-four (24) hours and an unauthorized <br /> release report submitted. <br /> The quarterly summary report shall be submitted within fifteen (15) days of <br /> the end of each quarter. Circle appropriate quarter. <br /> Quarter 1 -(1January-_-------->March) <br /> Quarter 2 - April ----------->June <br /> Quarter 3 - July ------------>September <br /> Quarter 4 - October --------->December <br /> Send to: SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. Hazelton Ave. , P.O. Box 2009 <br /> Stockton, CA 95201 <br /> {209) 468-3420 <br />