Laserfiche WebLink
INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: �G;iy/E /,��ff 1�,W Tank # Size Product <br /> 00� <br /> Facility Address: le'A se) <br /> ,Si�cyrx,ll �'�/L �S i•o / <br /> Telephone : <br /> Person Fill g <br /> Report � �GP�c� e. Grc� <br /> 1: 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 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank 11 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 I - January --> March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton , P .O . Box 2009 DEC 1 b 1'J00 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 ENVIRUMENTAL HEALTH <br /> FERMIT/SERVICES <br />