Laserfiche WebLink
(EXAMPLE ONLY) <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name :�,ERP�S II„1F'►rl � /�'► �Y1��.i Tank* Size Product <br /> Faci l ity Address : s t C k,St-��f� la's �-�-.-r <br /> Li qty, ? (goo ,vim D EP <br /> L <br /> ` I hereby certify under penalty of perjury that all inventory <br /> a variations for the above mentioned facility were within allowable <br /> limits for thisquarter . (No in Column 13 of the Inventory <br /> Reconciliation Sheet . ) <br /> a Inventory variations exceeded the allowable limits for this quarter . <br /> I hereby certify under penalty of perjury that the source for the <br /> variation was not due to an unauthorized ( leak) release . (Yes in <br /> Column 13 of the Inventory Reconciliation Sheet .) <br /> List date, tank N , and amount for all variations that exceeded <br /> the allowable limits: <br /> Date Tank 0 Amount <br /> 1 . <br /> 2 . <br /> 3 . <br /> 4 . <br /> 5 . <br /> Additional dates/amounts shall be continued on a separate sheet <br /> of paper and attached . <br /> If the source of the variation which exceeded allowable limits was due to a <br /> leak , the incident shall be reported to Madera County Environmental Health <br /> within 24 Hours at (209) 675-7823 . The Madera County Office of Emergency <br /> Services at (209) 675-7791 shall be notified in cases of an emergency . An <br /> Unauthorized Release Report shall be submitted to the Madera County <br /> Environmental Health Dept . within 5 days . <br /> The quarterly Summary report shall be submitted within 15 days of the end of <br /> each quarter . <br /> Quarter 1 - January --> March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> Sf1J 500i�k)i rJ <br /> Send t o : - rA-DZ N—AL--REA LTH <br /> UNDERGROUND-ST-GRA <br /> VE <br /> 9 <br />