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INVF-NTORY RECONCILIATION - <br /> , �= Y STJM.MA_RY REPORT FORM - <br /> . <br /> F-: c F-: 4t Name: T <br /> 41 L Tank-1 , <br /> r S t P � or Cit1(•'y- <br /> �,Facility Address: <br /> Telephone: I <br /> Person Filing I <br /> Report: I <br /> i <br /> (� I hereby certify under penalty' of perjury that all inventory <br /> �-J variations for the above mentioned facility were within the <br /> allowable limits for this qua_—ter. (No in column 2.3 of the <br /> Inventory Reconciliation Sheet- ) <br /> �( Inventory variations exceeded the allowable limizs for this t <br /> �..1 Quarter. I hereby certify under penalty of perjury that the <br /> source Por the variation was not due 'to authorized (leak) <br /> release. <br /> Sheet) . (Yes in Column 13 of the Inventory Reconciliation <br /> List date, tank ji, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Date Tank = Amount <br /> Reason <br /> 2 . J01 <br /> 2 • Lod <br /> 4;- <br /> Additional <br /> -- <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 qua -ter. Circle appropriate qua_"ter. <br /> Quarter 1 January--- >March <br /> Qua=ver 2 - Anril ----------->June .• <br /> Quarter 3 - July <br /> Quarter 4 October --- <br /> nd to: SAM JOAQUIN COUNTY PUBLIC HEALTH SERVIC=S <br /> E.*tVIRONMENTAL FiE.�LT:i DIVISION - <br /> - 1.601 E. Hazelton Ave: , P.O. Box 2009 <br /> - - Stockton, -CA. . 9520L :.. . <br /> (209) 468-3420 <br /> E.i 22 019 (1-0/89) . <br />