Laserfiche WebLink
INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: a � I Tank # size Product <br /> CW d A Oi <br /> Facility Address: Y �/'�. //�' S !. <br /> Telephone : 0?n - a2aq- <br /> Person Filing <br /> Report '�y 001,10ast,' <br /> 0 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. (Ho in Colum 13of the inventory Reconciliation Sheet) <br /> ElInventory 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 an unauthorized (leak) release. (Yes in Colum I3 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank it, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank # Amount _� /� /j!- fj <br /> 1. Tld�•�R. �G�Cl1 46U 404K <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued .on a separate sheet of <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 Healrh <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within IS days of the end of each <br /> quarter. <br /> Quarter I - January March <br /> Qrsarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 R. Haze ] Loll , P .O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UCT 40 10/86 <br />