Laserfiche WebLink
INVENTORY RECONCILIATION w'.AY v apt <br /> QUARTERLY SUMMARY REPORT FORM ENVIROMENTAL HEALTH <br /> FERMIT/SERVICES <br /> Facility Name: rr4Taa 1 env, Tank ! Size Product <br /> Facility Address: pj� �J, /44*444;� <br /> Telephone : 466 - 37 <br /> Person Filin <br /> Report /%�j�/y,LD <br /> INI 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 /> vas not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank i, and amount for all variations that exceeded the <br /> allowable limits_ <br /> Date Tank ! Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <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 11 <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --) September <br /> Quarter 4 - October --> Oecomber <br /> Send to: SAN JOAQUIN 1.0CA1, HEALTIi DISTRICT <br /> 160L K . Har.cllun , P .O . Rom 2009 <br /> Stockton , CA 95201 466 -67bl <br /> UGT 40 10/ H6 <br />