Laserfiche WebLink
INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM y �� '1997 <br /> Facility Name: ' Tank roductYa <br /> Ka <br /> Facility Address: -(]Q <br /> Telephone : (�C�� '�lQ ` 03 <br /> Person Filing <br /> Report L ���t <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 /> 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 f 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 <br /> Quarter 2 - April ---> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October ---> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT EEE' .I LD <br /> 1601 E . Hazelton , P .O . Box 2009 <br /> SPR 17 1987 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 1 143 j fJU:'P i'EA Tr4 <br /> A[WI ISTRATION <br />