Laserfiche WebLink
INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> FaciLlty Name: , ' , C / DG/� 7arr� Tank E <br /> Size. Product <br /> yacilit Address: G e <br /> Y to'/ <br /> Telephone : p ' e s e <br /> Person Fill <br /> Report <br /> hereby certify under penalty of perjury that al <br /> the above mentioned facility were within the allovabLe limitsfor this <br /> s for <br /> quarter. (Ito in Column 13of the inventory Reconciliation iSheet) <br /> I <br /> Inventory variations exceeded theallowable limits for this quarter. i <br /> hereby certify tinder penalty of perjury that the source for the variation <br /> was not due to an unauthorized (teak) releise. (Yes in Column 13 of the <br /> taventory Reconciliation Sheet) ^'" I <br /> List date, tank f}, and amount for all variations that exceeded the <br /> allovable Limits. <br /> Date Tank 0 Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> i <br /> Additional dates/amounts shall be continued on a sepairate sheet of <br /> paper and attached. <br /> if the source of the variation which. exceeded al-lovable limits was due to <br /> a leak the incident shall be reporter! to S .J . L.H . 0. Environmental Health <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterl suawar <br /> Y y report shall be submitted within 15 days o�E the end of each <br /> quarter. <br /> Quarter l - January --) march <br /> Q'Jarter 2 - April --) June <br /> Quarter ] - July --) September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> 160 [ E. I'laze 1 t-on , P .O . JJ()x 1009 <br /> Stockton , CA 95201 466-6781 <br /> (IGT 40 10/86 <br />