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'INVENTORY RECONCILIATION , <br /> ­t'= r.Y SUMI'LFkRY REPORT F67e, <br /> l ' <br /> Facility Name: J + rl•4c_.c �- 4 , size <br /> pr t <br /> ��r acilit Address: <br /> / y <br /> "Telephone: <br /> Person Filing <br /> Report: <br /> (� I hereby certify under penalty, of perjury that all inventory <br /> l-J variations for the above mentioned facility were within the <br /> allowable limits for this quarter. ( La in column 13 of the <br /> Inventory Reconciliation Sheet. ) <br /> i <br /> QInventory variations exceeded the allowable limits for this <br /> quarter. I hereby certify under penalty of perjury that the <br /> source far 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 an% Reason <br /> kL <br /> 4 : <br /> S . <br /> Additional datas/amounts shall be. continued on a separate <br /> sheet of 'paper and attached. <br /> If the sources 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 'tuienty-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, I Circle appropriate quarter. <br /> Quarter 1 - January---------->March <br /> Quarter 2 - April -----------XTune <br /> Quarter 3 - July ----------->September - <br /> Quarter 4 - October --------->Decamber <br /> . , SAN JOAQUIN COUNTY PUBLIC HEALTH SF.RVICEs <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. Hazelton Ave:, P.Q. Box 2009 -:- <br /> Stockton, CA 95202 = - <br /> (209) 468--342a <br /> EH 23 019 (10/89) 4 <br />