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INVENTORY RECONCILIATI(_ <br /> QUARTERLY SUMMARY REPORT FORM <br /> y <br /> Facility Name: W\0'01i Tank -# i Size I Product i <br /> Facility Address: <br /> Telephone: C;C, <br /> Person Filing <br /> Report: l X:l.1� � �� 1�✓ cl <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 <br /> Reason <br /> 1. <br /> 2 . <br /> 3 . <br /> 4 . <br /> 7 . - <br /> 5• .................... <br /> AG221991 <br /> ENVIRO MENTAL HEALTH <br /> Additional dates amounts shall be co LTi �I', <br /> �n�t OVICES <br /> h'dd5 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 /> - January---------->March <br /> `c. Quarter April <br /> - ----------->June <br /> uarter 3 - July ------------>September <br /> Quarter 4 - October --------->December <br /> Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. Hazelton Ave. , P.O. Box 2009 <br /> Stockton, CA 95201 <br /> EH 23 019 (10/89) (209) 468-3420 <br />