Laserfiche WebLink
INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Names Pacific Bell _l Tank # I Size I Product <br /> _) 1 ! 25. 364 I Diesel I <br /> Facility Address: 345 N. San Joaquin J 2 1 25`364 I Diesel I <br /> Stockton, CA I 3 1 25364 1 Diesel j <br /> Telephones (209) 442-2222 I <br /> Person Filing ( I <br /> Reports Fleet Su vr. <br /> x I hereby certify under penalty of perjury that all inventory <br /> variations for the above mentioned facility were within the <br /> allowable limits for this quarter. (No in column 13 of the <br /> Inventory Reconciliation 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 #, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Date TAnk_J Amount Reason <br /> 1. <br /> 2. <br /> 3 . <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 /> 4uarter 1 - Ja --- arch <br /> uarter 2 - A >June <br /> Quar er 3 - July------------> ep ember <br /> Quarter 4 - October--------->December <br /> Send to: SAN JOAQUIN COUNTY 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 /> EH 23 019 (10/89) <br />