Laserfiche WebLink
! • /o- <br /> INVENTORY RECONCILIATION <br /> Ohi T QUARTERLY SUMMARY REPORT FORM <br /> EF* .. <br /> ENVI0 ,99 <br /> . LAN <br /> p`!c°�C3irVee r Tank # Size Product <br /> J yl/ y. X00 <br /> Facility Address: y o o 14 <br /> Telephone : <br /> Person FilingT <br /> Report 1 Gln 7 7 <br /> dhereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable limits for this <br /> et) <br /> quarter. (Ho in Column 13of the Inventory Reconciliation She <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 #, 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 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 /> Quarter I - January March <br /> Quarter 2 - April June <br /> Quarter 3 - July --) September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . HazelLMI , P . O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/ 86 <br />