Laserfiche WebLink
\11 <br />R� • . 0 RECEIVED <br />INVENTORY RECONCILIATION JUN 2 5 1991 <br />QUARTERLY SUMMARY REPORT FORM <br />ENVIRONMENTAL HEALTH <br />Facility Name: '-\r, k; 1AN2 LAtJ10►J <br />Facility Address: -7 0I W. McvA L N''i <br />Telephone: x-11 <br />Person Fil' g <br />Report: <br />I hereby certify under penalty 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 />Inventory variations exceeded the allowable limits for this <br />quarter. 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 limits. <br />Date <br />5. ► IZ--`�I <br />Tank <br />Z. <br />Z <br />Z <br />mount <br />I Li <br />12, <br />Reason <br />Additional dates/amounts shall be continued on <br />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 <br />Public <br />Health Services of San Joaquin County.Environmental Health <br />Division, within twenty-four (24) hours and an unauthorized <br />release report submitted. <br />The quarterly summary report shall be submitted within fifteen <br />(15) days of <br />the end of each quarter. Circle appropriate quarter. <br />January ----------- <br />Quarter 1 - Januar->March <br />MARCH LANE OMON 76 <br />Quarter 2 - April <br />Quarter 3 - July _1� <br />2701 W MARCH LANE <br />STOCKTON, <br />' `--------->September <br />CA 95219 <br />Quarter 4 - October' ---------->December <br />209.473.7337 <br />19527157 <br />Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />(209) 468-3420 <br />EH 23 019 (10/89) <br />