Laserfiche WebLink
INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: F✓°�— Tank t Size Product <br /> Facility Address: e/ Ov �i _ ;Lz- / ° - 7 <br /> Ul1C �ecq 233-- Jam Ct <br /> Telephone : ivy- X 39- a?17 <br /> Person Filing <br /> Report 2H <br /> E] 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 13of the Inventory Reconciliation Sheet) <br /> Srul ul 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 /> / <br /> 3. - <br /> 4114 <br /> 3. <br /> 4. <br /> 111t,FS 4TH <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 LOCA1, HEALTH DISTRICT <br /> 1601 E . Hazelton , P . O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UCT 40 10/86 <br />