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V <br />Facility Name: <br />INVENTORY RECONCILI ON <br />QUARTERLY SUMMARY REPONT FORM <br />i)* v/ to - Nni� <br />Facility Address: /`{0/ u./, r -r'"",(^" <br />Telephone: NG <br />Person FiliD9 , <br />Report: 1-4w <br />-rlr 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 Reconcilipticen <br />Sheet) . <br />List date, tank ♦, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Date Tank I Amount Reason <br />2. t_W <br />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 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 o: <br />the end of each quarter. Circle appropriate quarter. <br />Quar_ 1 - January ---------- >March <br />uarter - 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 />