Laserfiche WebLink
,m * MONITORING ALTERNATIVE #5 qor /e <br /> l� Inventory Reconciliation <br /> Quarterly Summanj Report Form <br /> Tank# Size Product <br /> Facility Name: rla A f'c���,�,A/ /000 G <br /> Facility Address: �y�y� /VAll n St. <br /> /�a�feca Ca 9533 <br /> Telephone: <br /> Person Filing Report:�/�/`�/ WO�i?OS� I <br /> Ua,/ I hereby certify under penalty of perjury that all inventory variations for the <br /> l!1 above mentioned facility were within the allowable limits for this quarter. <br /> (NO in column 13 of the Inventory Reconciliation Sheet.) <br /> Inventory variations exceeded the allowable limits for this quarter. I hereby <br /> ❑ certify under penalty of perjury that the source for the variation was not due <br /> to unauthorized (leak) release. (YES in Column 13 of the Inventory <br /> Reconciliation Sheet.) <br /> U <br /> List date, tank number, and amount for all variations that exceeded the APR 4 1991 <br /> allowable limits. LIWIRiONMENTAL HEALTH <br /> Date Tank# Amount PERMIT/SERVICES <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 a leak, <br /> the incident shall be reported to San Joaquin County Public Health Services; <br /> Environmental Health Services, within twenty-four (24) hours and an <br /> unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within fifteen (15) days of the end of <br /> each quarter. <br /> Quarter 1: January 0 March <br /> Quarter 2: April June <br /> Quarter 3: July September <br /> Quarter 4: October N December <br /> Send To: <br /> San Joaquin County Public Health Services <br /> Environmental Health Services <br /> Post Office Box 2009 <br /> Stockton, CA 95201 <br /> (209) 468-3420 <br /> EHS 23 019 10/86 <br />