Laserfiche WebLink
INVENTORY RECONCILIATION <br />C QUARTERLY SUMMARY REPORT FORM <br />facility Name:Frt I-txal l� 1,k'"7 <br />Nacility Addreses ��% A . M f} <br />Te lephone : . ,? / - -1. .5 <br />Person cling <br />Reports1�� f`ye x Q <br />J U L 19 1989 <br />=Eri �• " <br />8M <br />QI hereby certify unJor penalty of perjury that all inventory variations for <br />the above mationed facility were within the allowable limits for this <br />quarter. (!lo 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 unauthorised (leak) release. (Yes in Column 13 of the <br />T <br />ft"Istory RaeoaeiliatiOn Sheet) <br />List date, tank #p and amount for all variations that exceeded the <br />allowable lis11ts. <br />Date Tank <br />1. Ll - _ r <br />2. H _)C__ v <br />i r -F3 r - <br />S.. t I -le,-1t <br />Amount j r r f 1 it i 1�1 fA L <br />�n8 VGA A- t�_, i AA)K- 15 C�i <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. Environmental Health <br />within 24 hours and an unauthorised release report submitted. <br />The quarterly sumary 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 DISTR�CT <br />1601 E. Haze"lton ,- -,P . 0 . Iiox 2009 <br />Stockton, CA 95201 466-6781 <br />UGT 40 10/86 <br />. <br />r <br />