Laserfiche WebLink
INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: "ge, /0'/t _ Tank I size Product <br /> f r, <br /> Facility Address: A/. A-71;70 as s/I7 �� <br /> Telephone : CV07 -a3Cf'3S'�►_� <br /> Person Fi1leglv <br /> Report -Z <br /> E] 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. 1 <br /> hereby certify under penalty of perjury that the source for the variation <br /> vas not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I a Amount <br /> 1. - <br /> 2. J <br /> 3. <br /> 4. <br /> S. <br /> Additional dates/amounts shall be continued .on a separate sheet of r <br /> paper and attached. <br /> If the source of the variation which- exceeded allowable limits was due to <br /> a leak the incident shall be reported to S .J .L .H _ D . Environmental Health <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 /> Qjarter 2 - April <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Y,aze l Lon , P .O . Box 2009 <br /> SLockton , CA 95201 466-6781 <br /> UGT 40 10/ 86 <br />