Laserfiche WebLink
INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: -�4�, <br />Facility Address: U <br />9 <br />Telephone: <br />Person Filing <br />Report <br />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 />Inventory variations exceeded the allowable limits for this quarter4. -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 f, and amount for all variations that exceeded the .. <br />allowable limits. <br />Date lank 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 at-lowable 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 be submitted within 15 days of the end of each <br />quarter. <br />Quarter I - January March t <br />Quarter 2 t—""April June <br />Quarter 3 - July September P <br />Quarter 4 - October December /I ) <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 />?), 9-f"7 <br />7V <br />AUG 0 1992 <br />