Laserfiche WebLink
INVENTORY RECONCILIATION GCT 3 1�3� <br /> QUARTERLY SUMMARY REPORT FORM <br /> �(� C��','II20Pdf✓ENTAL Hv',LTH <br /> Facility Name: O ' C�i�11r1��Ctt(�L �IC4YYUL/ Tank # iz Product <br /> l <br /> Facility Address: IG 250 L tJpici Q� <br /> Telephone : �(�° ' �631a <br /> Person Filing <br /> Report � 6pn <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 column 13 of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury that the souree for the variation <br /> was not due to an unauthorized (leak) release. (Yes in Column 13 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 # 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 I — January Nnrch <br /> Quarter 2 - April --> June <br /> arter 3 - July --> September ('189 <br /> Quarter 4 — October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P . O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 <br />