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INVENTORY RECONCILIATIANP <br />QUARTERLY SUMMARY REPORT FORM, <br />Facility Name: <br />'2 ' I <br />`_e Facility <br />X <br />HWMI r� A� <br />Fm <br />I hereby certify under penalty of perjury that all inventory <br />variations for the above mentioned facility were within the <br />allowable limits for this quarter. (Ro_ in column 13 of the <br />Inventory Reconciliation Sheet.) <br />Inventory variations exceeded the allowable limits for this <br />quarter. I hereby certifv 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 />V <br />List date, tank #I amount for ail variations and the reason <br />for exceeding the allowable limits. <br />Date <br />Reason <br />4. 3 1 <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 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 />Quarter 1 - January ---------- >March <br />Quarter 2 - April ----------- >June ,EIVED <br />Quarter 3 - July ------------ >September1,00 <br />Send to: Quarter 4 - October --------- >December ENVIRONMENTAL MEALTH <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESPERMIf /SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />EH 23 019 (10/89) (209) 468-3420 AMU <br />a <br />