Laserfiche WebLink
INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM. <br /> Facility Name: r� © Tank t.5izProduct <br /> Facility,Address: G/ Gr/ Gl/ Sf'iG�.✓ f <br /> Te Iephone :/'z� 1 -ol' -e241K <br /> Person Filing <br /> Report <br /> I hertby certify under penalty of perjury that all 'inventory variations for <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (Ho in Column 13 of the lovec'tory Reconciliation Sheet) <br /> ElInventory 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) relelse. (Yes in COW= 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tack 1, and amount for all, variations that exceeded the <br /> allowable limics. <br /> Date Tank 0 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 ind attached. <br /> .f Clot source of the variation which. exceeded allowable iimitS was due to <br /> a leak the incident shall be reported to S .J ,L.H .D. Environmenta l Hca l th <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within 15 days of th d of each <br /> quarto. � <br /> Quarter 1 •- January --) March t <br /> iarter 2 - A --) n <br /> Q' April June <br /> Quarter 3 - July --3 5cptcmba„r,� ,q `14N 6 198 <br /> uQuarter 4October <br /> _ U <br /> ------ actobcr --) Dcccmb r � � �r�'pi?Ua1;�,nr- <br /> RMI;iERV'r�rhLr� <br /> Send co_ SAN JOAQUIN LOCAL HEALTH DISTRICT �£S <br /> 1601 E. Haze 1 tail . P .O . Box 2009 <br /> Stockton , Cil 95201 466-6781 <br /> JGT 40 10/ 86 <br />