Laserfiche WebLink
INVENTOR 41 <br />Y RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: -�7 4i6 <br />Facility Address: -1�12 w• 14+nr1,-4 L.r� <br />Telephone: <br />Person Filing <br />Report: ria e- TWtc�' <br />Tank i <br />AP R, 201992 <br />NVIR(tis (tis 'i, HE <br />oo�' tai! lr.�,el <br />Lj cX <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. (HQ in column 13 of the <br />Inventory Reconciliation Sheet.) <br />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 <br />2. <br />3. <br />4. <br />5. <br />Ta <br />Amount <br />Reason <br />Additional dates/amounts shall be continued on a separate <br />sheet of paper and attached. <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 approp ate quarter. <br />Quarter 1 - ---- --- <br />Q January >March <br />Quarter 2 - April ----------->June <br />Quarter 3 - July ------------>September <br />Quarter 4 - October --------->December <br />Send to: SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />(209) 468-3420 <br />