Laserfiche WebLink
r• <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: _P-909Atr,S XXOA/ 3 <br />Facility Address: o?Q%a IAA,410A <br />%em j'r- Ayr--_ . <br />7A1q-r CAi gS,`3LD <br />Telephone: Al3G - 57S <br />Person Filing <br />Report CA Ro L_ 14pW F LL <br />W, 18)ir• I us 4a <br />0 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 quarter. 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 #, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank # <br />2. "1-0--86- <br />3. :2 <br />4. <br />.Amount <br />111 <br />_.IF_ <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 allowable limits was due to <br />a leak the incident shall be reported to S,J •L,H.D. Enviroc=ertal 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 1 - January --> March <br />Quarter 2 - April --> June <br />Quarter 3 - July --> September <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201. 466-6781 <br />UGT 40 10/86 <br />J <br />