Laserfiche WebLink
ai <br /> �ti`n <br /> \ IN <br /> "P <br /> INVENTORY RECONCILIATION <br /> f��FC2� <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: �c �f1DaAJryac�; ,,4{ C �. Tank I Sine. Product <br /> Facility,'Address; oic•cy��2Tc"•2 w•¢/ �f �, <br /> Cfr>cK7r� 9s Zo4- <br /> Telephone : <br /> pTelephone : (, �,Q,� :�1, 6,z_o3 a3 <br /> Person Filing <br /> Report _&A - <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> -he 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 that exceeded the <br /> allowable licnits. <br /> Date Tank 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 whichexceeded 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 submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January March <br /> Ql er 2 <br /> Quarter 3 --July --S September <br /> QuarCer 4 - October --> (k-cember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . H 1ze 11 o�n , P .O . 1iox 2009 <br /> Stockton . CA 95201 466-67bl <br /> !IGT 40 10/86 <br />