Laserfiche WebLink
ENVIRONMENTAL HEALTH <br /> INVENTORY RECONCILIATION PERMITISERVICES <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: V0 k _-s—, LIQ /[; Tank I Size Product <br /> /6�4O r <br /> Facility Address: �j I / 1") S3 - <br /> �—qot- ; , GAa DEQ <br /> Telephoner —I� H <br /> Person Filing n <br /> Report �s dJAJ'ACtilt' Q <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 13 of the Inventory Reconciliation Sheet) <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 as unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank F Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be contioued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation whichexceeded allowable limits was due to <br /> a leak the incident shall be reported to S .J . L.H . D . Environmental Ilcalth <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 3 - July --) Jeptcmhcr <br /> Quarter 4 - October --> Dkcember <br /> Send to: SAN JOAQUIN LOCM. HEAL1'li DISTRICT <br /> + 1601 E . Ilazt II a I' .0 . Rom 2009 <br /> SLockuon • CA 95201 466-6781 <br /> UI;1' 40 10/ 86 <br />