Laserfiche WebLink
P) 9--D <br />• <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: Lts.gwvo,�tbrc' <br />Facility Address: 23(. Y-) <br />`-,..0 a " ciSZti{ A <br />Telephone: 3-31 \-k Z 2 4 l <br />Person Filing <br />Report t' e � A <br />Tank # Size Product <br />Sim e.o <br />O aO-C, <br />O 0,5! o L►�nl— <br />Li 0 0 o 0, d L=+ <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 />q.sarter. (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 per, 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 I Amount <br />2. <br />3. <br />4. <br />5. <br />Additional daces/2.mounts 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 su.:_..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 HE."%LTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />UCT 40 10/86 <br />