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0 INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: �- rL ,j/" <br /> Tank Size i Product <br /> Facility Address: <br /> Telephone: <br /> Person Filing <br /> Report: A <br /> I hereby certify under penalty of perjury th 1 �fx�try <br /> variations for the above mentioned facility within' <br /> allowable limits for this quarter. (No in cin = 3. �.of..' th <br /> Inventory Reconciliation Sheet. ) �- <br /> n Inventory variations exceeded the allowabl i � ETi� t$ T <br /> t---� quarter. I hereby certify under penalty of pLiE6h*T1/,4ffiWfte <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 /> Date Tank 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 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 tvienty-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 <br /> Quarter 3 - July ------------>Septem <br /> uarter 4 - October --------->Decem er �i"2 <br /> Send to: SAN JOA C 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 />