Laserfiche WebLink
Inventory Reconciliation; QnarteiiY Summary Report Form <br /> DATE: <br /> Facility NaSize P <br /> Name: E roduct <br /> F Kludt L. Sons Inc, 1 20 000 Unl Plus <br /> r Facility Address : 1126 E. Pine Str,;et 20 000 Re lar <br /> 20 00 Diesel <br /> Tele hone: Iodi Ca 952 0 2 OOD Kerosene <br /> P 209 68-063 or ! 0-39 9 2 000 Solvent <br /> Person ing <br /> Report; <br /> ® <br /> this <br /> herebycerti y under penalty ofor the above mentioned facilit perjury that all inventor quarter. (No in Column 13y were within the allowable tion, for of the Inventory Reconciliation' Sheet, <br /> ❑ Inventory variations exceeded the allowable limits for ) <br /> hereby certify under Penalty of perjury that the this <br /> tion was not due to source for thervaria-I <br /> the Inventor unauthorized ( leak) release, {yes in Column 13 of <br /> { y Reconciliation Sheet) <br /> i' List date, tank 0 , and amount for <br /> gall variations that exceeded <br /> the allowable limits . <br /> Date Tank # <br /> 1 r Amount <br /> -- <br /> 2 . <br /> ------ <br /> 3 . <br /> 9 . <br /> 5. <br /> Additional dates/amounCs <br /> paper and attached, shall be continued on a separate sheet <br /> If the source of the variation which exceeded allowable limits was <br /> due to a leak, the incident shall be reported to San Joaquin Local <br /> Health District; be <br /> Health Division, within twenty-four <br /> ( 24 ) hours and an unauthorized release report submitted, <br /> The quarterly summary report shall be submitted within fifteen ( 15 ) days <br /> of the end of each quarter. <br /> uarter 1 January----------> <br /> March <br /> Quarter 2 - April----------- <br /> Quarter 3 ->June <br /> July------------->September <br /> Quarter 4 - October----------->December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton, P,O, Box 2009 <br /> EH 23 019 10/86 Stockton, CA 95201 468-3420 <br /> * (!lake a S0PY (vellow) for Kludt W22 Wand e,tt ch invonto lieconciliation records for <br /> .. all tanks. ) -------- <br />