Laserfiche WebLink
INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: l 1 C C(I-M J Ck�- V (cM--1 <br />Facility Address: � Q ( W <br />Telephone: ')O� <br />Person Filing / <br />Repo t ' bRS�-- <br />D C� <br />-, APR 5 1988 <br />EIyVIRO!�EN!AL HEALTH <br />�cQMll"/SERv10ES <br />Tank # Size Product <br />hi <br />t <br />I 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 Colu® 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 an unauthorized (leak) release. (Yes in Column l3 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 f <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 whichexceeded 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 I - January --) March <br />Quarter 2 - April --> June <br />Quarter I - July --> Scptcmh4-r <br />Q4iarter 4 - October --) fk:cember <br />Send to: SAN JOAQU I N LOCAL HEAI.'1'1i DI STK ICl' <br />1601 I•;. Haze 1 t On , P.O. 1tOx <br />2009 <br />Ic;'I' 40 10/86 SLockLOn. CAA 5201 466-6181 <br />