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2 0 Up je'CINVENTORYRECONCILIATION <br />�zw ( Z'7t TERLY SUMMARY REPORT FOR <br />Facility Name <br />Facility Addreoss.: <br />Telephone: <br />Person Fil <br />Report: _ <br />M <br />variT6e ei penalty of perjury that all inventory <br />iEs Mol t above mentioned facility were within the <br />limits <br />allowable 1 for t <br />(No in column 13 of the <br />tion 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 1, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Date ft Tank <br />2. 111 U <br />U <br />3 e <br />4 sU Nc- 2a?A P U- <br />5. <br />Amount <br />�4- 9 <br />C> <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 />QuarterJanuary ---------- >March <br />Quarterk- April ----------- >June <br />Quarter 3 - July ------------ >September <br />Quarter 4 - October --------- >December <br />Send to: SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />(209) 468-3420 <br />