Laserfiche WebLink
INVENTORY RECONCILIA`1'ION C�' <br /> <' QUARTERLY SUMMARY REPORT FORM <br /> PERIM0.(/E R`/1 Cr-" <br /> Facility Name:) ✓111ti1(Z-1 Tank Size/ AVProduct P-C <br /> Facility Address: <br /> 'Z <br /> Telephone:_CZ('At --597 <br /> Person Fi�C'J i.ng <br /> Report: <br /> u�- C A, <br /> I hereby certify under_ penalty of perjury that all inventory variations <br /> ❑ for the above mentioned facility were within the allowable limits for <br /> this 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 varia- <br /> tion was not due to unauthorized ( leak) release. (Yes in Column 13 of <br /> the Inventory Reconciliation Sheet ) . <br /> List date, tank If , and amount for all variations that exceeded <br /> the allowable limits . <br /> Date Tank # Amount <br /> 1 . -:� % / 093 <br /> 2 . �� i 7L 3 S� <br /> 3 . <br /> 4 . <br /> 5 . `�._ 4 I-L <br /> Additionaldates/amounts shall be continued on a separate sheet <br /> paper and attached. <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; Environmental 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 /> Quarter 1 - January---------->March 4pr. 15 <br /> Quay-L 2 - April------------>June .3-kI l-9 <br /> uarter July------------->September Oct/5 <br /> Quarter 4 - October---------->December -- u41 IS <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton, P.O. Box 2009 <br /> Stockton, CA 95201 468-3420 <br /> EII 23 019 10/86 <br />