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INVENTORY RECONCILIATIONS <br /> Y SUM�LkRY REPORT FORM <br /> 14 /y�ya <br /> Facility Name: "+ :►,r c <br /> Tank <br /> u t <br /> Facility Address: <br /> Telephone: <br /> Person Filing <br /> Report: <br /> ElI 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. (H-0 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. (]Les 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 <br /> __ T_ank 9 Amou..nt Reason <br /> 2 . <br /> 4 <br /> 5. <br /> Additional dates/amounts shall becontinued 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 l - January---------->March <br /> Quarter 2 - April ----------->June <br /> Quarter 3 - July ------------>September <br /> Quarter 4 October -------- <br /> ->December � T -�- <br /> A nd to: , SAN JOAQQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Er <br /> IRONMENTAL HEALTH DIVISION <br /> ,. 1.601 E. Hazelton Ave.' , P.O.- Box 2009 <br /> Stockton, CA 95201 <br /> EH 23 014 (10/89) (209) 468-3420 ` ' <br /> f <br />