Laserfiche WebLink
INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Names Tank Size Product <br />Fac ility Address <br />--",Joe <br />Telephone: <br />Person Filing <br />Report VT <br />I.-/') <br />1 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 Colum= 13 of the Inventory Reconciliation Sheet) <br />® 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 as unauthorized (leak) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date. tank 1® and amount for all variations that exceeded the <br />allowable liatits. <br />Date Tank f Amount <br />3 k <br />Z I3 i cc <br />3. <br />4. EK''IRONPicj- --FA _ HEALTH <br />S. <br />FERIAIVSERVICES <br />Additional dates/amounts shall be continued on a separate sheet of <br />paper znd attached. <br />If the source of the variation which. exceeded at -towable limits was due to <br />a leak the incident shall be reported to S.J.L.H.D. Environmental liealth <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 1 - January --J March <br />Q•Aartcr 2 - April --> Jure• <br />Quarter l - July --) September <br />Q%Aarter 4 - October --> [)4-cember <br />Send to: SAN JOAQUIN LOCAL, HEALTH DISTRICT" <br />1601 E. Haze 1 t (in . P.O. Rox 2009 <br />Seockton. CA 95201 466-61b1 <br />IGT 40 10/86 <br />