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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT Fol <br />Facility Name: Pacific Bell I Tank # I Size I Product I <br />Facility Address: 1812 Coley Ave. I 1 I 500 I DieselI I I <br />Escalon, CA 1 <br />Telephone: (209)442-2222 1 ( I <br />Person Fill g J <br />Report: - Fleet Su vr, I I <br />xO I 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. (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 #, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Date Tank <br />1. <br />2. <br />3. <br />4. <br />5. <br />Amount Reason <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 />uarter 1 - Januarv--_------->March <br />`�?uar er 2 - A r� L----------� <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 />