Laserfiche WebLink
INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name. <br /> Tank i Size <br /> Facility•Address: 13a'Coyo� Product <br /> Telephone : --�— rry, <br /> Person Filinge� <br /> Report <br /> �Lr <br /> dI hereby certify under <br /> the above penalty of perjury that all inventory variations for <br /> mentioned facility veer within the allowable limits for this <br /> quarter. (No in Columu 13 of the laveacory Reconciliation Sheet) <br /> ❑ Inventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under, penalty of perjury Cha[ the source for the variation <br /> Column 13 of the <br /> was sol due to as unauthorized (Irak) release. (Yes is <br /> Iaveatory Reconciliation Sheer) <br /> List date, tank " and amount for all variations chat exceeded the <br /> allowable linica_ <br /> -a_te Tank f Amouat <br /> i_ <br /> PC <br /> 4. c, �� <br /> 5. JUL <br /> 1 198 <br /> ENTER MENTAL HEAL <br /> 11 <br /> Additional dates/amoucc' shall be continued on a separate sheet of <br /> Paper and attached. <br /> Lf the source of the variation which. cxceeded allowable limits was due to <br /> A leak the incident shall be reported to S .J . L. H . D. <br /> Within 24 hours and an unauthorized release report submiccedonmcnCal Bealth <br /> The quarterly summary reporc shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter 1 - Jaauary --> march <br /> Q•.arccr 2 - ApriL --> Jw„e <br /> QuarCcr ] - July <br /> QvarCcr 4 _ Occobcr --> DeDecember <br /> Send cc: SAN JOAQUIN LOCAL HEALTH UIS'I'R1C-1- <br /> 1601 E. 1jaze11 (41 , p .0 . Ilox 2OOg <br /> a' 40 10/ 86 SLockton , (,`A 45201 466-67b1 <br />