Laserfiche WebLink
INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: ) �,` Z—,4- (J Jz, Tank # Size Product <br /> -r- U <br /> Facility Address. G7 4 '7 }Ll a� . . PA <br /> Telephone : c.� gc/ p-,) -7 <br /> Person Filing <br /> Report L, ' <br /> C 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 /> vas 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 it Amount <br /> 1. J - q LIZ -r 33_ L <br /> 2. Z-/7 + 3(.- / <br /> 3. Z 7-- / 7 <br /> 4. + 3 , f <br /> S. <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 aLlowabie 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 --5 September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Fazelton , P .O . Box 2009 <br /> SCockCon , CA 95201 466-6751 <br /> UGT 40 10/ 86 <br />