Laserfiche WebLink
INVENTORY RECONCILIATIL <br /> QUARTERLY SUMMARY REPORT FORM <br /> y <br /> Facility Name: 1 _ i Tank -# i Size Product <br /> d Po <br /> �-' Facility Address: l/ 5����/f Pli'/eJ <br /> L't Ec'.� n/ 6Q,afr 0>7. <br /> Telephone: '�Zoq u:a - L-/ ? i'e <br /> Person Filing <br /> Report: _ t n 1p_4� <br /> I hereby certify under penalty of perjury that all inventory <br /> variations for the above mentioned facility were within the <br /> allowable limits for this quarter. (No in column 13 of the <br /> Inventory Reconciliation Sheet. ) <br /> 7� 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) . <br /> List date, tank #, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Date Tank Amount <br /> Reason <br /> I. <br /> 2 . <br /> 3 . <br /> 4 .5. , <br /> t <br /> 22 <br /> Additional dates/amounts shall be con�inlRONMENTAL_ HEALTH <br /> sheet of paper and attached. Effm F ate <br /> If the source of the variation which exceeded allowable limits <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 /> y�j91 _Quarters - Januar <br /> Quarter 2 - January---------- <br /> April -->June <br /> Quarter 3 - July ------------>September <br /> Quarter 4 - October --------->December <br /> Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. Hazelton Ave. , P.O. Box 2009 <br /> Stockton, CA 95201 <br /> EH 23 019 (10/89) (2 09) 468-3420 <br />