Laserfiche WebLink
INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY RFPORT FORM <br /> Facility Name: Q:j[+ ��k+n(n Tank / Size Product <br /> Facility Address: � �, ( Ii-),nc r <br /> Telephone : Gti ,� �JLC <br /> Person Filing <br /> Report _��y Gu" -, 1 <br /> 1 hereby certify `under penalty of perjury that all inventory variations for <br /> the above mentionedfacility were within the allowable limits for this <br /> quarter. (Ho innCo Colu® i3 of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable limits for this quarter. v� <br /> hereby certify under penalty of perjury that the source for the v Is 0 <br /> was not due to an unauthorized (leak) release. (Yes in Column 13 '> <br /> A, <br /> Inventory Inventory Reconciliation Sheet) � <br /> h <br /> List date, tank /, and amount for all variations that exceeded th`,,�'; �\N. <br /> allowable limits_ <br /> Date Tank I Amount <br /> 2. <br /> ]. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a seoarate 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 $ .) 1, 11 . 0 _ 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 /> Quarccr I - January --) March <br /> Q•ia r[cr 2 - April --) June <br /> N <br /> Quarter J - July __) .le ptember N <br /> Quarter 4 - October --) December 1N <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISIItICT <br /> 1 601 l: . Haze I t un , 11 O <br /> Stockton , CA WJ201 1466 0 /bl <br /> 0r.1 40 I0/ 84 <br />