Laserfiche WebLink
o N • <br />INVENTORY RECONCILIATI <br />11 QUARTERLY <br />SUMMARY REPORT FORM <br />1.�� law QOfl <br />Facility Name: C]'7 C1 L -JL k� 3 <br />Facility Address: Z-3,4,. <br />Y1 N,rar•r. <br />-Lpy , GA <br />Telephone: 33 1 - 7-7-4( <br />Person Filing <br />Tank # Size <br />Product <br />oao <br />j O oa o _ <br />tire` <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. (Ko in Column 13 of the Inventory Reconciliation Sheet) <br />E] Inventory 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) release. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank #, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank # Amount <br />2. <br />3. <br />4. <br />5. <br />Additional dates/amoubts 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 sur-:ary 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 --> September <br />Quarter 4 - October December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />UCT 40 10/86 <br />