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w <br /> i NW INVENTORY WCONCILIATION <br /> wary SUMMARY REPORT F0 , <br /> Facility Name: -J r t^. r <br /> CT to <br /> Facility Address: <br /> - -Telephone: <br /> Person Filing I <br /> Report: I <br /> I hereby certify under penalty o f 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 al t <br /> quarter. I hereby certifyunder Towable Limits for this <br /> 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 t, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Data ITIanj �sount aReason <br /> twz <br /> 2 . <br /> r <br /> 3 . <br /> 4 : <br /> S. <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---------->March <br /> Quarter 2 - April ------------. <br /> Tune <br /> Quarter 3 - Jul ------------>Septeptember <br /> Quarter 4 -- October --------->Decamher . <br /> d to; SAO*[ JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL. HEALTH DIVISION <br /> 1601 E. Hazelton Ave:, P.O. Box 2009 <br /> Stockton, CA 95201 - <br /> E-H 23 019 (10/89) (209) 468-3420 `_ <br />