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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: �O'� r� an �'� if: C i Tank # i Size i Product i <br /> 2 3500C L CIL. G,as" LC_ <br /> Facility Address: 2N3 1 E M r1�2i �oSA k0' <br /> s ock—o � ca �,s2c's <br /> Telephone: <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 /> List date, tank #, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Date Tank Amount Reason <br /> O/�S 7f C K nCAO <br /> 1. / iS 8`" /00, 3 Eiziro2. <br /> 2 . <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 of <br /> the end of each quarter. Circle appropriate quarter. <br /> Quarter 1 - January---------->March <br /> Quarter 2 - April ----------->June a Y` 39 <br /> Qu 3 - July ------------>September d <br /> Quarter 4-1- October --------->December FEB - 9 9° �7 <br /> Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES :.",1TALHEALTH <br /> �i ENVIRONMENTAL HEALTH DIVISION _1" 1T/.SEP,y 0.CS <br /> 1601 E. Hazelton Ave. , P.O. Box 2009 <br /> Stockton, CA 95201 <br /> (209) 468-3420 <br /> EH 23 019 (10/89) <br />