Laserfiche WebLink
INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: L,)(y�(y�� (CIf�LIrLtl�(Ll� i� Tank # Size Product <br /> Facility Address: 102,'3D L Wf el) <br /> Telephone : <br /> Person Filing <br /> Report ` T-( 1 <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 source 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 #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank # Amount <br /> z. U <br /> 3. JAN 6 3989 <br /> 4. ENV IRONMEiNTAL HEALTH <br /> 5. <br /> PERMIT/SERViCES <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 --) March <br /> Quarter 2 - April --> June <br /> / Quarter 3 . - July --> September <br /> CQuarter 4 October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P .O . Box 2009 <br /> Stockton , CA 95201 466-678.1 <br /> UGT 40 10/86 \ <br />