Laserfiche WebLink
INVENTORY RECONCILIATI`/ <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Facility Address: IL/O/ <br />Telephone: /!•C -CI <br />Person Filing <br />Report: 1-4'w+ ai ",Ut " <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. (F2 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 ,f, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Date Tank I AmountReason <br />00 q ft <br />2. - -- <br />3. <br />4. <br />5. <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 fifteen (15) days of <br />the end of each quarter. Circle appropriate quarter. <br />Quarter 1 - Januar >March p.. <br />January CE1 <br />uarter 2 - April ----------->June <br />Quarter July ------------>September OCT 9 lo0q <br />u ter 4 - o •. >ber--------->DecembeENVIRONMENTAL HEALTH <br />Send to: SAN JOAQUIN PUBLIC HEALTH SERVICES PERMIT/SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 9!,201 <br />(209) 468-3420 <br />