Laserfiche WebLink
INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name:(-'-r EWE Tank / Size Product <br /> n MO c �l- <br /> Facility4ddress: /py[,s <br /> A 5—P .4 <br /> Telephone : 4,YAA- 6 x Sac <br /> Person Filing <br /> Report Z-Art (,yE'0L/VE*CL- <br /> l3 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. (No in Column 13 of the inventory Reconciliation Sheet) <br /> 0 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) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Task / Amount A 1 Ic4p <br /> 2. UU U 1988 <br /> 3. ENVIROMENTAL HEALTH <br /> 4. FERMIT/SERVICES <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 Health <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 I - January --) Harch <br /> Quarter 2 - April --) June <br /> Quarter 3 - July --) Septcmher <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160L 1: . Haze l l (ni . P . O . 1 ox 2009 <br /> Stockton . CA 95201 466 -6761 <br /> UCT 40 10/86 <br />