Laserfiche WebLink
A( r- a0PL- L FA1Z *: <br /> ENTORY RECONCILI?.TION <br /> t4BralaSUMMARY REPORT FORM. <br /> � ,a�rlv�I y <br /> Facility Name: 1. 1 r l.1 CATO V,� "r vAjLb5 1 Tank i Size i Product <br /> f o rj-&o It ICA F_D C A <br /> Facility Address: 1200t $ 1IwHwAy99 00 e F� <br /> 1 A4d EcA} Eed rS�3c <br /> Telephone: fav r\ zsn - r zr <br /> Person Filing- <br /> Report: !Zzc ,a AR-o LA v> &n J <br /> (� I hereby certify under penalty of perjury that all inventory <br /> variations for the above mentioned facility were within the <br /> allowable limits for this quarter. (No in column 13 of the <br /> Inventory Reconciliation Sheet. ) <br /> ❑ Inventory variations exceeded the allowable limits for this <br /> quarter. I hereby certify under penalty of perjury that the <br /> source for the variation was not due to authorized (leak) <br /> release. (Yes in Column 13 of the Inventory Reconciliation <br /> Sheet) . <br /> List date, tank J, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Date Tank OF Amount Reason <br /> 1. <br /> 2. <br /> 3 . <br /> 4 . <br /> 5 . <br /> Additional dates/amounts shall be continued on a separate <br /> sheet of paper and attached. <br /> If the source of the variation which exceeded allowable limits <br /> was due to a leak, the incident shall be reported to Public <br /> Health Services of San Joaquin County. Environmental Health <br /> Division, within twenty-four (24) hours and an unauthorized <br /> release report submitted. <br /> The quarterly summary report shall be submitted within fifteen (15) days of <br /> the end of each quarter. Circle appropriate 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 COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. Hazelton Ave. , P.O. Box 2009 <br /> Stockton, CA 95201 <br /> EH 23 019 (10/89) (209) 468-3420 <br />