Laserfiche WebLink
Facility <br />v l tl VA <br />v� INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM JUL 3 '�� <br />k ---n r1 . 0 1 <br />Name: <br />Facility Address: <br />Telephone :�� 6 <br />Person Filing <br />Report: <br />[ j I rereby certify under penalty of perjury that all inventory <br />variations for the above mentioned facility were within the allowable <br />limits for this quarter. (No in Column 13 of the Inventory <br />Reconciliation Sheet). <br />] Inventory variations exceeded the allowable limits for this quarter. <br />I Hereby certify under penalty of perjury that the source for the <br />variation was not due to an unauthorized (leak) release. (Yes in <br />Column 13 of the Inventory Reconciliation Sheet). <br />List date, tank #, and amount for all variations that exceeded the <br />al-nwahla limits_ /17 f <br />Amount' " <br />2q t� <br />K �Q <br />be continued on a separate sheet of <br />pager and a L. do e 3 <br />If the source of the variation which exceeded allowable limits was due <br />to a leak the incident shall be reported to S.J.L.H.D. Environmental <br />Health within 24 -hours and an unauthorized release report submitted. <br />Date Tank # <br />1. <br />2. i <br />3 - a <br />4. <br />5- <br />i t'?�6natlf dates/amounts shall <br />, t h A <br />The quarterly summary report shall be submitted within 15 days of the <br />end of each quarter. <br />Quarter <br />1 <br />- January --> <br />March <br />Quarter <br />2 -- <br />April --> <br />June <br />Quarter <br />3 <br />- July --? <br />September <br />Quarter <br />4 <br />- October ---> <br />December <br />Send to: <br />SAN JOAQUIN <br />LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P. 0. Box 2009 <br />Stockton, <br />CA 95201 466-6781 <br />T 40 lo/86 <br />