Laserfiche WebLink
INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORMV� <br /> Facility Names 1`/v�/ ( G �p �p ��J✓ <br /> —�_ it T Tank t Size Prod <br /> ll» <br /> Facility Address: C)ryAiN <br /> Telephone : <br /> Person Fn-g <br /> Report <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. (Ho 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 Columm 13 of the <br /> Inventory Reconciliation Sheet) <br /> i <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank / Amount <br /> 1. <br /> 2- <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on it separate sheet of <br /> paper and attached. <br /> If the source of the variation which. exceeded at-lovable limits was due to <br /> At 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 Fubmitted 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 4 - occober --> Ikeember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DIS'T'RICT <br /> 1601 F. , HaZe I L(ui . P .0 _ Box 2009 <br /> Stockton , CA 95201 466 -6181 <br /> '40 l0/ N6 <br />