Laserfiche WebLink
INVENTORY RECONCILIATION1,�;HE <br /> QUARTERLY SUMMARY REPORT FORM30CT —, or+ <br /> FaciLity. Names i` ice, tank Sise. <br /> Product <br /> lacilit �Addresssr 10 r"c 3a �� tJ �a�j m r-r� 5 z r rev kf <br /> Telephone : �,i1� i G 4( <br /> Person Filing <br /> Report <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. (Ho 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) release. (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 limits. <br /> Date Tank f Amount <br /> 1. <br /> 2. <br /> 3. -4 <br /> 4. <br /> S. 4 �_ � �� � ti - CA3 <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. erceeded 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 1 - January --) March <br /> Q'larter 2 - April --> June <br /> Quarter 3 - July September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160L E . haze 1 <<�n , P . O . Box 2009 <br /> Scockton ,- CA 95201 466-67b1 <br /> ;T 40 10/ 86 <br />