Laserfiche WebLink
INVENTORY RECONCILIATION <br /> EWRIERi'EALTH <br /> QUARTERLY SUMMARY REPORT FORM PERMIT/SERVICES <br /> ' <br /> FaeiLity Name: MIAI Tank I Site u pediluet <br /> lacility,Add[ess; <br /> Telephone : <br /> — <br /> Person Fili <br /> Report <br /> t=1 • 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 13of the Inventory Reconciliation Sheet) <br /> ❑ Inventory variations exceeded the allowable limits for this quarter. 2 <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to no unauthorized (leak) release. (Tet in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date. tank /, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <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 Ncalth <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly susmiry r�POrt-ahal.L.be_ submitted within 15 days of the end of each <br /> quarter. - <br /> C Qua/ ctcr_i_\ January <br /> Quarter 2 - -April --> June <br /> Quarter 3 - July --) Scptcmb(:r <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN U)CAL HEALTH DISTRICT <br /> 1601 E. llazelton . 11 .0 . Box 2009 <br /> Suockton . CA 95201 466-67hl <br /> EH 23 019 10/86 <br />