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I <br />INVENTORY RECONCILIATi-Olp <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: Tank # Size <br />Facility Address: <br />Telephone: <br />Person Filing <br />Report: <br />P <br />I hereby certify under penalty of perjury that all inventory <br />'Al <br />variations for the above mentioned facility wer <br />allowable limits for this quarter. (No in colo <br />Inventory Reconciliation Sheet.) WrOEIVED <br />Inventory variations exceeded the allowable limitso Pir I A 109 0 <br />quarter. I hereby certify under penalty of p&0AftNtWWALhWEALTH <br />source for the variation was not due 'to authorizOOKAWRVICES <br />release. (Yes in Column 13 of the Inventory Reconciliation <br />Sheet). <br />List date, tank J, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Date Tank I Amount Reason <br />1. <br />2. <br />3. <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.,all:owa+�le 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 A (15) days of. <br />the end of each quarter. Circle appropriate quarter. <br />Quarter 1 - January ---------- >March <br />Quarter 2 - -----> un <br />er 3 - July ----------- --- to <br />>December <br />Send to: SAN JOAQUIN COUNTY 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 />EH 23 019 (10/89) <br />