Laserfiche WebLink
IHYENTORY•RECOHCILIAT IOn 0 <br />RTERLY SUMMARY REPORT FORM <br />FaeiliCT Name.`' ) j I r k! Tit <br />Facility AddreA P' <br />Telephone: <br />Person Filing <br />Report��t'r� <br />HI hereby certify under peaaltT of perjury that all inventory variations for <br />the above mentioned facility were within the allowable limits for this <br />quarter. (No in Coluca 13 of the Inventory SeconciliaCion Sheet) <br />QInventory variations exceeded the allowable Limits for this quarter.••I <br />hereby certify under penalty of perjury that Che source for the variation <br />vis not due CO an unauthorized (leak) release. (Yes in Column of the <br />Inventory Reconciliation Sheet) '— <br />List date, Cank t, exceeded the and amount for all variatioes that <br />allowable limics. _ <br />Date rank <br />�— Amount <br />3. <br />4. <br />S. <br />Additional dates/amounts shall be continued on a separate sheet of <br />P Per and attached. <br />If Che source of the variation which exceeded allowable limits was due to <br />a leak the incident shall be reported to <br />within 24 hours and an unauthorized relcas.J.L .H..Dbm Environmental <br />viitteomental Health <br />Inc quarterly summary report shall be submitted within 15 days of the and of <br />each <br />quarter. <br />Quarter 1 January —> !larch <br />Quarter 2 April —> June <br />Quartet 3 ri July —> Septembers <br />Quarter 4 — October —> December l <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT. <br />1601 E. Hazelton, P.O. Box 2009 <br />11GT 40 10/86 Stockton, CA 95201 466-6781 <br />