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'INVENTORY RL'CONCILL3TIO N - <br /> =- X SUMMARY REPORT FORM ' <br /> 41 <br /> Facility Name. Y _ - t Tank r S{ ' u Pro <br /> Facilit � ���� <br /> f y Address: <br /> .•-`"Telephone: <br /> Person Filing <br /> Report: <br /> QI 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 va_r-iations and the reason <br /> for exceeding the allowable limits. <br /> Date Tank 0 Amount Reason <br /> 2 . <br /> - 2 <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 (LS) days of <br /> the end of each quarter. Circle appropriate quarter. <br /> Quarter 1 - January---------->March <br /> Quarter 2 - April ----------->tiTune <br /> Quarter 3 - July -------------,September - - <br /> _ Quarter 4 -- October --------->December <br /> encd to: SAN JOAQUIN COUNTY_PUBLIC HEALTH SERVICES <br /> ENVIRONMF-NTAL HEALTH DIVISION <br /> L60L E. Hazelton Ave:, D.O. Box 2009 <br /> n Stockton, CA 35201 - - <br /> EH 23 0?9 (10/89} (209) 458-0420 <br />