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INVENT RECONCILIATIOP i <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name Pacific Bell Tank # 1 Size Product <br /> 1 3, 551 Diesel <br /> Facility Address: 907 Lincoln Road <br /> Stockton, CA <br /> Telephone: (209) 442-2222 <br /> Person Filing <br /> Report: �. � Fleet Supvr. <br /> X I hereby certify under penalty of perjury that all <br /> inventory variations for the above mentioned facility were <br /> within the allowable limits for this quarter. (No in <br /> Column 13 of the Inventory Reconciliation Sheet) . <br /> Inventory variations exceeded the allowable limits for this <br /> quarter. I hereby certify under penalty of perjury that <br /> the source for the variation was not due to authorized <br /> (leak) release. (Yes in Column 13 of the Inventory <br /> Reconciliation Sheet) . <br /> List date, tank #, amount for all variations and the <br /> reason for exceeding the allowable limits. <br /> Date Tank # Amount Reason <br /> 1. <br /> 2 . <br /> 3. <br /> 4 . <br /> 5. <br /> Additional dates/amounts shall be continued on a <br /> separate sheet of paper and attached. <br /> If the source of the variation which exceeded allowable <br /> limits was due to a leak, the incident shall be reported <br /> to Public Health Services of San Joaquin County <br /> Environmental Health Division, within twenty-four (24) <br /> hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within fifteen (15) days <br /> of the end of each quarter. Circle appropriate quarter. <br /> Quarter 1 - January---------March <br /> Qu 2 - April,--. <br /> Quarter 3 - July------------September <br /> Quarter 4 - October---------December <br /> Send to: SAN JOAQUIN COUNTY 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 /> EH 23 019 (10/89) <br />