Laserfiche WebLink
INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: .,. Cfrim&{c�c�\- 5 ilc, Tank Size Product <br /> Facility Address: 1oZ50 LjiA(-, <br /> Telephone : (Lgs)- S -o8-) 3 <br /> Person Filing <br /> Report , <br /> dI 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 /> vas not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank it, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> 4, <br /> EP3V1Fi0ME"+ISL HEALTH <br /> 5. FE.RU111-/SERV10ES <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 aliowabike limits was dry tc <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 I - January --> March <br /> arte _2F1 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1.601 E . Hazelton , P .O . Dox 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 4 <br />