Laserfiche WebLink
0 ENED <br /> 0 <br /> INVENTORY. RECONCILIATION OCT 2 4 1991 <br /> QUARTERLY SUMMARY REPORT FORM r HEALTH <br /> Facility Name: <br /> Tank P <br /> 1,2 C/L'It'l <br /> Facility Addres!, <br /> Wp <br /> Telephone: <br /> t�C> 0 7 <br /> Person Filing -7 <br /> Report: <br /> hereby certify under penalty of perjury that all inventory <br /> variations for the above mentioned facility were within the <br /> allowable <br /> llowable limits for this quarter. (No in column 13 of the <br /> - Inventory Pconcili on 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 f, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Date Tank Amount Reason <br /> 1. <br /> 2. <br /> 3 . <br /> r� <br /> 4 . <br /> 5. <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 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 (15) days of <br /> the end of each quarter. Circle appropriate quarter. <br /> Quarter 1 - January---------->March <br /> Quarter 2 -`April_, _ - <br /> Quarter -------- <br /> July --�-->�Se p t�em b e�r — <br /> July <br /> Quarte <br /> send to: SAN JOAQUIN 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 />