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INVENTORY RECONCILIATION <br /> �QUARTERLY SUMMARY REPORT FORM <br /> Facility Name:-CXl� (� Tank size Product <br /> /I <br /> 60 D <br /> Facility Address: "SY &%e! .ri_//��' <br /> 57sacKte ✓ 7 <br /> Telephone: 9yi - ij 71 <br /> Person Filing <br /> Report: �- <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 R Reason <br /> 1. &-!)1) - 1'3— 7JL�_ <br /> 2 . <br /> 3 . <br /> 4 . <br /> 5. <br /> Additional dates/amounts 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 San 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--,January---------->Marc-h -_ <br /> Quarte 2 <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 />