Laserfiche WebLink
INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: t�e' � � 4✓lC�� <br />Facility Address: <br />Telephone: c - 11 6 3 6 <br />Person Filing— <br />Report <br />Tank # Size Product <br />/ /Q0 c)o <br />n, v <br />0 1154 <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 Column 13 of the Inventory Reconciliation Sheet) <br />QInventory 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) 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 limits. <br />Date Tank f Amount <br />1. <br />3. <br />4. <br />5. <br />Additional dates/amounts 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 liea It <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 --) March <br />Quarter 2 - April --> June <br />Quarter 3 - July --> Septcmhcr <br />Quarter 4 - October --) December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Haze l t<,n , P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />L1C;T 40 10/86 <br />RECEIVED <br />DEC 2 0 :-A <br />ENVIRONMENTAL Hr` -'TH <br />PERMi11S I& -R V <br />