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yr INVENTORY RECONCILIATION "-W <br /> SLY SUMMARY REPORT FORM <br /> �nrva/y - .. • <br /> Facility Name: Tank .9 Size^ <br /> t <br /> Facility Address: <br /> _'Telephone: <br /> Person Filing <br /> Report: <br /> QY hereby certify under penalty, of perjury that all inventory <br /> �-J variations for the above mentioned facility were within the <br /> allowable limits for this quarter. (Eg in column 13 of the <br /> Inventory Reconciliation Sheet. ) <br /> n 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 /> Data Tank 0 &mou,,nt Reason <br /> 2 . <br /> 3 . <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 (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 ------------>September <br /> Quarter 4 - October ----------->December <br /> end to: , SAN JOAQUIN COUNTYaPUBLIC HEALTH SERVICES <br /> " ENVIRONMENTAL HEALTH DIVISION <br /> - 1601 E. Hazelton Ave: , P.O. - Box 2009 <br /> Stockton, CA 95201 <br /> (2 09) 468--3420 <br /> EH 23 019 (10/89) 4 <br />