Laserfiche WebLink
INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: �.e,�r. �t�leeeroY�a1 t-(_expTT� Tank Size Product <br /> Facility Address: 5 - <br /> Telephone : <br /> ?Telephone : -?3L(- 3,q'( (-. x c/zo <br /> Person Filing <br /> Report <br /> IN 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. (No in Column 13 of the Inventory Reconciliation Sheet) <br /> QInventory 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 1, and amount for all variatioas that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <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 Health <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall '.6"e submitted within 15 days of the end of each <br /> Quarter: <br /> Quarter I - January --? March <br /> Quarter 2 - April --> Juree <br /> - July --> September <br /> Quarter 4 October --> [k:cember <br /> Send to: SAN JOAQUIN LOCAL HEAL'1'li DISTIUCT <br /> 1601 E. hazel loth , P .O . Box 2009 <br /> Stockton , CA 95201 466-67b1 <br /> ;;Z' <br /> 1,0 ' 10/86 <br />