Laserfiche WebLink
INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> laeility Name: tank Size I Product <br /> I O OJJ <br /> F&cLILcy•Address: a ✓l. IW _ <br /> Telephone : (Jan) 335 - 396 -7 91io ouo <br /> Person Filing <br /> Report �� � � <br /> 0 6✓�7wlSE£ SrPiMrre RfAx-Y <br /> C] I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the sLLowabld limits for this <br /> Quarter. (No in CoLumm 13 of the 'Inventory Reconciliation Sheet) <br /> 0z'Inventorr 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) rcleise. (Yes in Colum 13 of the <br /> Inventory Reconciliation Sheet) �,,<..�_ �o-c-«no t% RPS 4-*_ � y� <br /> List date, tank !, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Yank ! /)mount L14 rj� TA�4 q,=,r _Itzy 77 <br /> 1. 7//� 3 8 <br /> 2. r713 _ l ' �p O Ph � Co <br /> 4. 9/3 3 LS 8/I z5. <br /> 8 <br /> Additional dates/amounts shall be contiould oo 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 Ucalth <br /> within 24 hours and an unauthorised 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 APR 4 <br /> �_Ouarter ) - July --> September 987 1 T988 <br /> —Quarter 4 - October --> Ikccmbcr ENVIROMENTAL HEALTH <br /> Send to: SAN JOAQUIN LOCAL HEALTU UIST K1CT FERMIT/SERVICES, <br /> 1601 E. 11azclt0n , P .O . 110x 21109 <br /> SLockton , CA 95201 466-61bl <br /> UCT 40 10/ 86 <br />