Laserfiche WebLink
i <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM � <br /> Facility Name: S Vnl - ST Tank # Size Product <br /> Facility Address: 6 S, � E L <br /> 14R- <br /> ey) -UALLJ--:4 6 L <br /> 5 3 3 -5 <br /> Telephone : �Q�= c2d5_22L7.7 <br /> Person F ling <br /> Report <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 Reconciliatioa�Sh a <br /> 4 <br /> Inventory variations ezceeded the allowable 'limits for Chis re <br /> bereby certify -under penalty of perjury that the source for a variation <br /> was not due to an unauthorized (leak) release. (Yes WaRMAKUTUAHEALTH <br /> Iovaatory Reconciliation sheet) PER MIT/SERVICES <br /> List datep tank #, and amount for all variations that exceeded the <br /> allowable Iia+i.ts. <br /> Date Tank f Amount <br /> 2. <br /> k 3. - ,4 <br /> 4. <br /> Additional dates/amouacs shall be '.contioued 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 dealth <br /> Within 24 hours and an unauthorized release report submitted. <br /> The quarterly sumsary report shall be Submitted within 15 days of the end of each <br /> • quarter. <br /> Quarter 1 - January --> March <br /> Quarter 2 - April --) June <br /> Quarter 3 - July ---) Septemher <br /> Quarter 4 - October ---) December <br /> Send to: SAN JOAQUIN LOCAL. HEALTH DISTINCT <br /> 1601 E . Hazelton , P .0 . Box .2009 <br /> Stockton , CA 95201 466-6781 , <br /> ' UGT 40 10/86 + <br />