Laserfiche WebLink
I- ENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM `�fa JA 3 O <br /> yv� W1 �121Cr�TTank# Size Product <br /> Facility Name: � <br /> Facility Address : bS2- h� gr722 O -t- <br /> 'lalephone: <br /> Person Filing <br /> Report: <br /> 0 1 kereby certify under penalty of perjury that all inventory variations for <br /> the above mentioaed facility were within the allowable limits for this <br /> quarter. (No Lm Colum 13of the loventory Reconciliation Sheet) <br /> y <br /> Inventory v+ri+tibas exceeded the allowable limits for thi• quarter. ' L <br /> hereby certify under peaaity of perjury chat the source for the variation <br /> was oat due to am uaauthorized (leak) release. (Yas in column 13 of the <br /> Inventory Racoaeiliatioa Sheet) <br /> List dates tack it and amount for all variations tk•t exceeded the <br /> allowable limits- Amount <br /> Date Tank # <br /> 1 . 1 .-----r 9 o .1 Ift <br /> h t�L 1 — g 5 <br /> 3. I— r, �a ApR � <br /> / 6 <br /> 9. �- <br /> - l-214 / <br /> 10. x— <br /> 11. 4 I LL /- io1 <br /> �,G, - 3J <br /> 12. <br /> 13. (� <br /> 14. / Z 2 Z v <br /> 15. <br /> 16. [f-S' 2 <br /> 17. /2- %Sr Z -34D <br /> -4 /-?- <br /> 18- 1 <br /> f X14 r <br /> 18. �/-� �- <br /> 19. 2./ -2'<ir- <br /> 20. <br /> 7? i ZG <br /> 22. // -/ 7 ( - Z55 / � SVY <br /> 23. '7 / Z 2_ / - / <br /> 24. �2 # / <br /> 25. - // 2- a <br /> 26.__-LJ- -Lo- <br /> 27. <br /> Lo-27. Z_ <br /> 28. <br /> 29.x_ <br /> 30. ---- <br /> 31.� <br /> Additional dates/amounts shall be concieued on a separate sheet of <br /> paper and attached. <br /> if the source of the variation whtch. exceeded al'lowableEl-im-"t wa -dal,e-to h <br /> a task the incident shall be reported to S .J .L.H.D. <br /> Uca <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 /> quarccr. <br /> Quarter 1 - January March <br /> Quarter 2 - April June <br /> Quarter 3 - July September <br /> Quarter 4 - October --> December <br /> Seal to: SAN JOAQUIN LOCAL HEALTH D1S-l'HICT <br /> 1601 E. Hazelt:,n . P .O. jinx 2009 <br /> . Stockton . CA 95201 466-6761 <br /> T 40 10/R6 <br />