Laserfiche WebLink
INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: L.J,'�,- \- , Tank I Size Product <br /> YU <br /> Facility Address; (, Z 1,7 ` �..v� - d G <br /> Telephone : (aa9) q Srfsa,,,Z 7 - <br /> Person Fil ' g <br /> Report C <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. (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 Tanis if Amount <br /> i. ZzLc T- 7 t '31 <` <br /> 2. 2Z,3 0 7- 17 t S�, q <br /> 3. 1 19, y-t 7 T_ 35�. z <br /> 5. Z, 17 + 3Y 7 <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 /> Garter 1 - January --> March <br /> Quarter 2 - April .lune <br /> Quarter 3 - .July --> September <br /> Quarter 4 - October --> December <br /> 'E'E " <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT rl <br /> 1601 E . Hazelton , P .O . Box 2009 APR 2 4 ,"-9 <br /> Stockton , CA 95201 466-6781 ENVIRONMENTAL HEALTH <br /> L1GT 40 10/86 PERMIT/SERVICES <br />