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f <br />t <br />INVENTORY.RECONCILIATI• <br />QUARTERLY SUMMARY REPORT FORN <br />61" <br />Address: <br />Telephone: <br />Person <br />e• / <br />Report: <br />e i •. •`.. 1 <br />CESIMN <br />w <br />jULw <br />ENVIRONMENTAL <br />r <br />I hereby certify under penalty of1perjury 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 f, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Date Tan <br />®u BAUM <br />1. <br />. <br />3. <br />4. <br />5. <br />Additional dates/amounts shall be continued on a <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 />uarter 1 - January ---------- ->March <br />Quarter 2 - April ---------- ->June <br />.Quarter 3 - July ----------=->September <br />Quarter 4 - October --------->December <br />Send to: SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH --.DIVISION <br />1601 E. Hazelton Ave., P.O. Box .2009 <br />Stockton, CA 95201 <br />(209) 468-3420 <br />