Laserfiche WebLink
• `w INVM4TORY RECONCILZATION � <br /> = �Y SUMMARY REPORT FORM <br /> Facility Name: s, Y,.; <br /> 41 Tank �E Si z? r P*- du t r <br /> Facility Address: <br /> Tei ephone: I <br /> Person Filing <br /> Report: I <br /> QT hereby Certify under pena?ty, of perjury that all inventory <br /> variations for the above mentioned facility were within the <br /> allowable limits for this quarter. (No in column 13 of the <br /> Inventory Reconciliation Sheet. ) <br /> Q ,nventory variations exceeded the allowable limits for this <br /> coat ter. I hereby certify under penalty of perjury that the <br /> source for the variation was not due to authorized (leak) <br /> release. (Yes in Column 13 of the Inventory Reconciliation <br /> Sheet) . <br /> List date, tank , amount for all variations and the reason <br /> for exceeding the allowable bits. <br /> Date Tank s mount Reason <br /> 2 .,i..l.C'�.0 L.♦ J <br /> Additional dates/amounts shall be continued on a separate <br /> sheet' of *paper and attached. <br /> If the source of the variation which exceeded allowable limits <br /> was due to a leak, the incident shall be reported to Public <br /> L ealth Services of San Joaquin County. Environmental Health <br /> Division, within twenty-four (24) hours and an unauthorized <br /> release report submitted. <br /> The quarterly summa_*-y report shall be submitted within fifteen (15) days of <br /> the end of each qua-•••ter. Circle appropriate quay ter. <br /> Quart-er 1 - January ->March <br /> Qua. ter 2 - April ----------->June <br /> Qua-"ter 3 - .July .->Seotemher = <br /> Quarter 4 - October --------->Decamher - - -- <br /> and to : SAN JOAQUIN COUNTY PUBLIC HFkLTH S-----IVT-CES <br /> 73 <br /> .•.. : - F�TVIRONM *iTAL %.LTH DIVISION - <br /> 1601 E. Hazelton Ave. , P.O. Box 2009 _ -- <br /> ^ : . Stockton, CA 95201 - <br /> (209) 463-3420 <br /> 7H 23 019 (;0/39) f <br />