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�INVENT0RY R�:CCilCST.L�TION*�„/ <br /> SUMP-ARY RSPORT FORM <br /> acility <br /> Name: -� ,-.,� <br /> L Tank size <br /> I <br /> Facility address: I I <br /> Telephone: I <br /> Person Filing <br /> I I <br /> Report: <br /> QI hereby certify under penalty' of perju..-,-y that all inventory <br /> variations for the above mentioned facility were within the <br /> allowable limits for this quarter. (,o in column 13 of the <br /> inventory Reconciliation Sheet. ) <br /> (� Inventory variations .. t <br /> L�l ons exceeded �..he allocable 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. - <br /> Sheet) . Column 13 of the Inventory Reconciliation <br /> List date, tank , amount for a1--1 variations and the reason <br /> for exceeding the allowable limits. <br /> Date <br /> Tank ;mount R=-son <br /> 2 . <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 <br /> Healthsha11 be reported to Public <br /> Services of San Joaquin County rnviio <br /> nmental health <br /> Division, within twenty-fou. ('24) hours and an unauthorized <br /> release report submitted. <br /> The quarterly summary report shall submitted <br /> the end of each be subm:� ed within fi*teen (15) days of <br /> h qua--te- . Circle appropriate quarter. <br /> Quarter 1 - January--------->March <br /> Quarter 2 - April ---------_ <br /> Quarter, 3 1 ->June <br /> Ju y _ --------__>September <br /> Quarter 4 - October --------->Decam�er . <br /> to: <br /> SAN .TOA UIN COUNTY P <br />:. Q UBL7 C ;I r' r�„ <br /> �`I <br /> =NVIRONMENTAL HF-A ,Tv TS�VICrS <br /> D-j1'IS_ON <br /> 1601 Hazelton Ave.' , P.O. Box 2009 <br /> Stockton, Ck 95201 <br /> r= <br /> 22 0'-9 (10/89) (209) 468-3420 <br />