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NEW INVENTORY -RECONCILIATION- <br /> . <br /> SUZ'-'4RrpaRT FORM <br /> �1 - <br /> Facili=y Name: 1, Y)„ <br /> t - Tank e <br /> acility Address: i <br /> I <br /> Te?ephone: <br /> Person Filing <br /> Report: <br /> QI hereby certi_y under penalty* of perjury that all inventory <br /> variations for the above mentioned facility were within the <br /> allowable limits for this quarter. (Ivo in column 13 of the <br /> Inventory Reconciliation Sheet. ) <br /> QInventory variations exceeded the allowable limits for this <br /> quarter. I hereby certify under penalty of perjury that the <br /> source far 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 x mount Reason <br /> 2 <br /> 3 • (L L.- <br /> /X-4 <br /> Additional dates/amounts shall be continued on a se_oa+rate <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 'twenty-four (24) hours and an unauthorized <br /> release report submitted. <br /> The quarterlysumma_�-y report shall be submitted within fifteen (15) days of <br /> the end of each qua_Tter. Circle appropriate quarter. <br /> Qua--ter 1 - January---------->March <br /> Quarter 2 - April ----------->June <br /> Quarter 3 - .July ------------>September <br /> Quarter 4 - October` --------->Decamber <br /> r`_�;'�e•^•� <br /> to: , SAN JOAQUIN COUNTY`PUBLIC HF-A.LTH SZ-VT_CES <br /> - F-NVIRONME.NTAL HEALTH DIVISION - - <br /> 1.601 E. Hazelton Ave.' , P.O. Box 2009 <br /> Stockton, CA 95201 - <br /> (209) 468-3420 <br />