Laserfiche WebLink
INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Fatality Name: ��V,'O/ 61iy� Tank # Size. <br /> Product <br /> Add <br /> Facitit ress: Z� "U <br /> r` _�o I S M r ]�2r.! z <br /> , <br /> Telephone : ff—Z-(0770 <br /> Person Filing �_ <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 Reconciliation Sheet) <br /> QInventory 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) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 1. <br /> z. � O <br /> 3. <br /> APR 0 6 1987 <br /> 4. <br /> 5_ ENVIROMENTAL HEALTH <br /> PERMIT/SERVICES <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 --) Scptembitr <br /> Quarter 4 - October --) DCCcmber <br /> Send to: SAN JOAQUIN I.00AL HEALTH DISTRICT <br /> 1601 E. Hazc 1 t onl , P .O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 <br />