Laserfiche WebLink
EC <br /> tMATORY RECONCILIATION <br /> NOV 2 1 <br /> QQUA TER(,Y SUMMARY REPORT FORM <br /> NU1RU. '^11ENTALHEALTH <br /> f <br /> Facility HLt {IiloffiWe" 1I _ <br /> Tank Site r <br /> Pc duet <br /> / <br /> Facility;Address:')':Z'576 Ar Cti1i` jQ / i SuPQ MF Uti& . <br /> CFI, o <br /> Telephone : c) c _ <br /> Person Fil g <br /> Report C /V - &f <br /> 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. (No in Column 13 of the Inventory Reconciliation Sheet) <br /> 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) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations chat exceeded the c <br /> allowable limits. <br /> Date Tank f Amount <br /> 1. <br /> 2. — <br /> 3. <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. exceeded 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 Rubmitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --1 March <br /> Quarter 2 - April --> June <br /> Quarter - July --> septemba:r <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH UISTKICT <br /> 1601 E. liazelton . P .O . Box 2009 <br /> Stockton . CA 95201 466-67b1 <br /> EH 23 019 10/86 <br />