Laserfiche WebLink
INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY <br /> REPORT FORM <br /> ra4dUty. Name: Tank i Sire Product <br /> raeilitp?Addresss �� QZZ. 9' 3 /� • <br /> Telephone/ 33 <br /> Person Fil n <br /> Report <br /> 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 Il of the inventory Reconciliation Sheet) <br /> e� <br /> '3 <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 an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank /, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank Amount <br /> 1. / /�? 3 -o? • F5- <br /> 2. 7 �� 3o�-a • /�/ f i <br /> 4. <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 March <br /> Quarter 2 - April --> June <br /> Quarter ] - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH ois- N cr <br /> 1601 E. Hazelton . 1' .0 . Box 2009 <br /> Stockton . CA 55201 466-67bl <br /> ;T 40 10/86 <br />