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INVENTRECONCILIATIOP <br />QUARTERL. SUMMARY REPORT FORM <br />Fe.cility Name Pacific Bell <br />Facility Address:3124 W. Elm Street <br />Lodi, CA <br />Telephone: (209) 442-2222 <br />Person Filing <br />Report: I zgd& Fleet Supvr^ <br />I hereby certify under penalty of perjury that all <br />inventory variations for the above mentioned facility were <br />within the allowable limits for this quarter. (No in <br />Column 13 of the Inventory Reconciliation Sheet). <br />X <br />Tank # <br />1 <br />Size <br />4,000 <br />Product <br />Diesel <br />Inventory variations exceeded the allowable limits for this <br />quarter. I hereby certify under penalty of perjury that <br />the source for the variation was not due to authorized <br />(leak) release. (Yes in Column 13 of the Inventory <br />Reconciliation Sheet). <br />List date, tank #, amount for all variations and the <br />reason for exceeding the allowable limits. <br />1. <br />2. <br />3. <br />4. <br />5. <br />rl' #® TonL- A <br />Amount Reason <br />Additional dates/amounts shall be continued on a <br />separate sheet of paper and attached. <br />If the source of the variation which exceeded allowable <br />limits was due to a leak, the incident shall be reported <br />to Public Health Services of San Joaquin County <br />Environmental Health Division, within twenty-four (24) <br />hours and an unauthorized release report submitted. <br />The quarterly summary report shall be submitted within fifteen (15) days <br />of the end of each quarter. Circle appropriate quarter. <br />Quarter 1 - January ---------March <br />Quarter w 2 ADW - June <br />Quarter 3 - JUI September_ <br />Quarter 4 - October ---------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 />