Laserfiche WebLink
r, <br />J <br />,L1� <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: m 3 <br />Facility Address: 23 4 <br />�L < 8331 6 <br />Telephone: (2C9i 549 3-I IS <br />Person Filj'�ng <br />Report T �Ylo�se <br />EFI hereby certify under penalty of perjury that all inventory variations for <br />the above mentioned facility were within the allowable limits for this <br />quarter. (No in Column 13 of the Inventory Reconciliation Sheet) <br />ElInventory variations exceeded the allowable Limits for this quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to as unauthorized (leak) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank 1, and amount for all variations that exceeded the <br />allowable limits. <br />Date tank I <br />1. <br />2. <br />3. <br />4. <br />5. <br />Amount <br />Additional dates/amounts shall be continued on a separate sheet of <br />paper and attached. <br />If the source of the variation which. exceeded allowable limits was due to <br />a leak the incident shall be reported to S.J.L.H.D. Environmental Health <br />Within 24 hours and an unauthorized release report submitted. <br />The quarterly summary report shall be submitted within 15 days of the end of each <br />quarter. <br />Quarter 1 - January --> March <br />Quarter 2 - April --> June <br />Quarter 3 - July --) Septemher <br />Quarter 4 - October --> December J01 61989 <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT ENVIRONMENTAL HEAL IH <br />1601 E. HazclLon, P.O. Box 2009 PERMIT/SERVICES <br />SLockton, CA 95201 466-6761 <br />UGT 40 10/86 <br />