Laserfiche WebLink
INVENTORY RECONCILIATION r 1 $8 <br /> QUARTERLY SUMMARY REPORT FORM DST 9 <br /> e°�wR<oNIAA N1rAL HcA17 <br /> __ c %A' i V!CES <br /> Facility Name: Gj)JZL KAAC1499 l�/Y/ Tank i Size Product <br /> Facility Address: _9W Mf4,k0/1 Ave <br /> MANTGGa GA <br /> Telephone : i 0 y' K2 c1 7, 5/ <br /> Person Filing.____ <br /> Report IGRk_J I A/65ib�FG <br /> nI 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 IJ of the Inventory Reconciliation Sheet) <br /> E] 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 an unauthorized (leak) release. (Yes in Column IJ of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank i, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> 1. <br /> 2. <br /> J. <br /> 4. <br /> S. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. eaceeded 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 1 - January --> March . <br /> Quarter 2 - April --> June <br /> Quarter J - July --> Septemh�c <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P . O . Box 2009 <br /> Stockton , CA 95201 466-67bl <br /> UGT 40 10/ 86 <br />