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INS:ORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: Cal — IrAn S. <br />Facility Address: p L4 S , ' ST <br />.S oc +on. CA, 95a06 <br />Telephone: q y d — �l� a0 <br />Person Fijing A <br />Report i=a c. A -FEV Inlpo <br />Tank i Size Product <br />101000 as <br />il 5 co r <br />L hereby certify under penalty of perjury that all inventory variatio%r <br />the above mentioned facility were within the allowable limits Eor G <br />quarter. (No in Column 13of the Inventory Reconciliation Sheet) <br />kW <br />Inventory variations exceeded the allowable limits for this qu#t*� <br />hereby certify under penalty of perjury that the source for @Re'v4riatioa @v J�6 <br />was not due to an unauthorized (leak) releise. (Yes in Colugm.l3 of the <br />Inventory Reconciliation Sheet) a �� <br />N���C� <br />List date, tank i, and amount for all variations that exceeded 4WV <br />allowable limits. IQ <br />Date Tank I Amount <br />l- Ian. � /W _/ i3 93 'Re4� s��c% wrong <br />i. ,f <br />3. <br />4. <br />s. <br />Additional dates/amounts shall be continued on a separate sheet of <br />paper .and attached. <br />It 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 />Send to: <br />January <br />--) <br />March <br />Quarter 2 - <br />April <br />--> <br />Junc <br />Quarter 3 - <br />July <br />--> <br />Septcmhcr <br />Quarter 4 - <br />October <br />--) <br />Dl comber <br />Send to: <br />