Laserfiche WebLink
�U <br />Facility Name: <br />INVENTORY RECONCIL7 'ION <br />QUARTERLY SUMMARY REPbra FORM <br />4 - <br />Facility Address: 11/01 U), <br />Telephone: W4 Oaf <br />Person Filing , <br />Report: l Nw+ F,! <br />I hereby certify under penalty of perjury that all inventory" <br />variations for the above mentioned facility were within the <br />allowable limits for this quarter. (No in column 13 of the <br />Inventory Reconciliation Sheet.) <br />Inventory variations exceeded the allowable limits for this <br />quarter. I hereby certify under penalty of perjury that the <br />source for the variation was not due to authorized (leak) <br />release. (Yes in Column 13 of the Inventory Reconciliation <br />Sheet). <br />List date, tank *, amount for all variations and the reasoi <br />for exceeding the allowable limits. <br />Date Tank <br />1. �--h—rob <br />2. <br />3. <br />4. <br />5. <br />Amount <br />Reason <br />Additional dates/amounts shall be continued on a separate <br />sheet of paper and attached. <br />If the source of the variation which exceeded allowable limits <br />was due to a leak, the incident shall be reported to Public <br />Health Services of San Joaquin County Environmental Health <br />Division, within twenty-four (24) hours and an unauthorized <br />release report submitted. <br />The quarterly summary report shall be submitted within <br />the end of each quarter. Circle appropriate quarter. <br />arter - January ---------- >March <br />Quar er 2 - April ----------->June <br />Quarter 3 - July ------------>September <br />Quarter 4 - October --------->December <br />fifteen (15) days o:. <br />Send to: SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 9:,201 <br />(209) 468-3420 <br />