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INV YTORY RECONCSI,LXTION <br /> SUMMARY REPORT FORM - <br /> c i i ty Name: <br /> 41 <br /> Tank-1 r Si <br /> `` Facility Address: <br /> Telephone: I <br /> Person Filing <br /> Report: <br /> Q1 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 t <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 t, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Date Tank = Amount <br /> Reason <br /> 2 . _Kra :(. . - � Q`'' <br /> 4 -• <br /> 5. <br /> Additional dates/amounts shall be. continued on a seo_ a=ate <br /> sheet of *paper and attached. <br /> If the sources 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 •t'r enty-f our (2 4) hours and an unauthorized <br /> release report submitted. <br /> The auazterly summary report shall be submitted within fi_teen (15) days of <br /> the end of each qua---ter. Circle appropriate qua..-•ter. <br /> Quarter 1 -' January- --- >March <br /> Qua_ter 2 - April <br /> _ Quarter 3 - July - >Septembe_,. <br /> Quar=er 4 October - >Decamber. -- - - <br /> � +nd to: , SAN JCAQUIN COUNTY PUBLIC HEALT.: SERVICES <br /> '`•�' ENVIRON21 .*iTAL H� ,T:i DIVISION <br /> 1601 E. Hazelton Ave: , P.O. Box 2009 ____._ __:. - .• -•-• -• <br /> - Stockton, -C.A.- - 95201 -.:.- <br /> (209) 403-3420 <br />