Laserfiche WebLink
Facility <br />I— ... 0 <br />NVENTORY RECONCILIATION <br />II QUARTERLY SUMMARY REPORT FORM <br />Name: P10'ra h &W P 0 00' NJ rI7 <br />Facility Address: L a' Sz <br />oGKk o <br />Telephone: 11 - <br />Person <br />1 -Person Fi 'ng <br />Report :Lo"C- <br />&' 3 <br />'° .,.<r ,s: M •i. +r f_r yam, <br />JUN 2 MMI <br />6NV1R01,j1v,Fn1,n1 <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 />i <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 />Tank <br />3 <br />3 <br />Amount <br />- 1s <br />+ <br />- 133 <br />a3� <br />Reason <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 <br />Public <br />Health Services of San Joaquin County,Environmental <br />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 />Quarter 1 - Januar - ------>March <br />MARCH LANE UNION 76 <br />Quarter 2 Apr. - --------->June <br />Quarter 3 - July - - --------->September <br />2701 W. MARCH LANE <br />STOCKTON, CA 95219 <br />Quarter 4 - October-/ --------- >December <br />209.473-7337 <br />19527167 <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 />