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INVENTORY RECONCILIATICe <br /> QG-3zRT-SR1,Y SUMMARY REPORT FORM - r <br /> Facility Name: Tank r Size i Product <br /> Facility Address: <br /> Telephone: <br /> Person Filing <br /> Report: <br /> 1 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 t, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Date Tank ; Amount Reason <br /> I+ <br /> 2 . / -fr C) <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 ------------>June <br /> Quarter 3 - July ..--__-- --->Septemkaer <br /> Quarter 4 October ------->Decamber - <br /> - ?nd to: , SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 'c•.:� ENVIRONME.NTAL HEkLTH DIVISION + <br /> - 1601 E. Hazelton Ave:, P.O. Box 2009 -__...: .... - <br /> Stockton, CA ' 95241 <br /> EH 23 019 (10/89) (209) 468-3420 <br />