Laserfiche WebLink
INVENTORY RECONCILIATION <br /> QUARTLRLY SUMMARY REPORT FORM <br /> Facility Name: Tank # Size Product <br /> Facility Address: <br /> Telephone: S/2_ .� <br /> Person, Filing , <br /> Report , h► <br /> I hereby certify under penalty of perjury that -all inventory variation: <br /> for the above mentioned facility were within the allowable limits for <br /> this quarter. (No in Column 13 of the Inventory Reconciliation Sheet. ; <br /> ❑ Inventory variations exceeded the allowable limits for this quarter. 1 <br /> hereby certify under penalty of perjury that the source for the varia- <br /> tion was not due to unauthorized ( leak) release. (Yes in Column 13 of <br /> the Inventory Reconciliation Sheet ) . <br /> List date, tank (f , and amount for all variations that exceeded <br /> the allowable limits . <br /> Date Tank H Amount <br /> 1. <br /> 11-Ir- 90 <br /> 3. <br /> 4 . <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet <br /> paper and attached. <br /> If the source of the variation which exceeded allowable limits was <br /> due to a leak, the incident shall be reported to San Joaquin Local <br /> Health District; Environmental Health Division, within twenty-four <br /> ( 24 ) hours and an unauthorized release report submitted . <br /> The gdarterly summary report shall be submitted within fifteen ( 15 ) days <br /> of the end of each quarter. <br /> Quarter 3. - January---------->March <br /> Quarter 2 - April---------- >June ! , `'• <br /> Q _uartcr 3. <br /> - July------------->September <br /> L�farter _4 - October--- ------jDecem ei""�- �f CC:S�Tjv <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton, P.O. Box 2009 <br /> Stockton, CA 95201 468-3420 <br /> a <br /> EH 23 019 10/86 <br />