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INVL14TORY RECONCILIATIO1 <br /> • ,QUARTERLY SUMMARY REPORT FOxM <br /> Facility Name: TEXACO FOOD MART & C/TA Tank I Size Product <br /> 1 10000 Rr- <br /> Facility Address: 440 West Charter Way 2 10000 ' r <br /> `.206 3 12000 " <br /> Telephone: Texaco q16 -3,61 7-6f,6 4 10000 T- l A2 <br /> Person Filing _ <br /> Report: Div t"kt ReT) '1I . J . Bartels _ <br /> I hereby certify unde-r penalty of perjury that all invento-y <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 /> 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 <br /> Quarter 3 - July ------------>September <br /> Quarter 4 - October <br /> Send to: SAN JOAQUIN PUI.,T 771 SERVICES <br /> 1601 E. Hazelton Ave. , P.O. Box 2009 <br /> Stockton, CA 95201 <br /> (209) 468-3420 <br />