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Co INVENTORY RECONCILI' '.ON <br />Facility Name: <br />QUARTERLY SUMMARY REPLTr FORM <br />Facility Address: I`10 ; W, <br />Telephone: <br />Person Fili:Dg , A <br />Report: 1-4'yo A>Ol�dgJ� <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 />C-' 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 reaso;i <br />for exceeding the allowable limits. <br />Date Tank <br />1.Ui) <br />2. <br />3. <br />4. <br />5. <br />Amount <br />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 e. <br />the end of each quarter. Circle appropriate quarter. <br />Qua - January ---------- >March <br />arter - April ----------->June <br />Qua 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 />