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ob INVENTORY, RECONCILIATIep,— <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: ('cmp.4a;, 3 Tank # Size Product_ <br /> 15- <br /> Facility Address: jF. 1r//qS7- <br /> Telephone: �2D43 <br /> Person Filing <br /> Report: ) <br /> 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 /> RECEIVED List date, tank #, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> OCT O 5 1602 Date Tank <br /> f PVIRONMENTALHEALTH Amount Reason <br /> PERMIT/SERVICES 1. <br /> > 2 . <br /> J 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 incid(,.. t 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 /> uarter - July ------------>September <br /> Quarter 4 - October --------->December <br /> JSend 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 />