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INVENTORY i <br />QUARTERLYSUMMARY <br />• ••ORT • <br />i <br />Facility Name: 0 i Tank_j i Size i Product i <br />Facility Address:ea,, V_ <br />Telephone: 41� „C31-3 <br />Person Filing <br />Report: _ r rte L --,yl,- I CO m <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. (No in column 13 of the <br />Inventory Reconciliation 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 #, amount for all variations and the reason <br />for exceeding the allowable limits. <br />/p <br />Date Tank Amount <br />3. <br />4. <br />5. <br />Reason <br />it <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 4. , <br />Quarter 2 - April -------- <br />--->June <br />Quarter 3 - July ------------>September <br />Quarter 4 - October --------->December <br />Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1-: <br />• e., ,0. Box 200_ , <br />Stockton, CA W2_0_1 <br />EH 23 019'(209) 468-3420 <br />(10/89) <br />