Laserfiche WebLink
;nTVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM . <br /> Facility Name: J)axs �L Tank # Size <br /> Product <br /> Facility Address: o <br /> Telephone: ~v rte e=C Twl� <br /> Person Filing <br /> r Report: <br /> I hereby certify under penalty of perjury that all inventory i <br /> variations for the above mentioned facility were withinll:the <br /> allowable limits far this quarter. (No in column 13 ofithe <br /> Inventory Reconciliation Sheet. ) <br /> Inventory variations- exceeded the allowable limits for this <br /> quarter. I hereby',� certify under penalty of perjury that the <br /> source for the variation was not due to authorized (leak) <br /> release. (Yes in Column 13 of the Inventory Reconciliation, <br /> Sheet) • i <br /> List date, tank #, amount for all variations and the reason <br /> for exceeding'the allowable limits. <br /> Date Tank # Amount : Reason <br /> 1. <br /> 3. L b <br /> OCT2 ` <br /> 5. PI� �NMI`d;AL HEA-'f <br /> Additional dates/amounts shall be continued on a separate <br /> sheet of paper and attached. <br /> If the source of the variation which exceeded allowablelimits <br /> was due to a leak, -the- incident shall be reported to Public <br /> Health Services of San Joaquin County Environmental Health <br /> Division, within twenty-four (24) hours and an unauthorized <br /> release report submitted. <br /> The quarterly summary report shall be submitted within fifteen (15) days of <br /> the end of each quarter. Circle appropriate quarter. <br /> Quarter 1. - January---------->March <br /> Quarter 2 - April ----------->June <br /> Quarte - July ------------>September <br /> Quarte 4 - October --------->December <br /> Send to: SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION - <br /> �f�S/1�, P.O. . Box 2009 <br /> Stockton, CA 95201 <br /> (209) 468-3420 <br />