Laserfiche WebLink
INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: G9L/F401?A7/I7 91"'11 XY n/47)?Of <br />F:eility<Addreaa: 38'u Lu FSTCRi4NTL//ur <br />S,PWPY cog 9537L <br />Telephone: 201 - 835- 89ZO <br />Person Filing <br />Report /I.uj, malle/9N * Y46Z <br />Tank I Size Product <br />19 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 Colusm 13 of the Inventory Reconciliation Sheet) <br />E] Inventory variations exceeded the allowable limits for this quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />vas sot due to an unauthorized (leak) relebse. (Yen in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank /, and aaount for all variations that exceeded the <br />allowable limits. <br />Date Tank f <br />3. <br />4. <br />5. <br />a; A " a <br />0 C T 9 1n"O <br />ENVIRONMENTAL HEASH <br />PERMIT/SERV.. 1'ESig <br />D <br />CD <br />n <br />D I <br />N <br />D 'Da) <br />Additional daces/z=. untz shall be continued on a ee;;arate ahcat 0§9 w <br />paper and attached. ;y v <br />If the source all the variation which.exceeded allowable lie:tz wast due to <br />a leek the incident shall be reported to S.J.L.H.D. Eovironmenta:L Ucalth <br />Within 24 hours and an unauthorizcd release rcport subuicced. <br />The quarterly sum ry report shzll be submitted within 15 day: of the end of each <br />quarter. <br />Quarter I - January --) Harch <br />Qiarter 2 - April --> June <br />ar[cr ] - JULY —> September 4' o <br />arccr 4 - October --) December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRtC1' <br />1601 E. HazelLM). P.O. Box 2009 <br />SLockcon. CA 95201 466-678L <br />T 40 10/H6 <br />r <br />