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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name:u. STTank i �V' <br />Fac ity Address: ?������� <br />Telephone: <br />Person Filing <br />Report <br />Product <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 13of 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 1, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank I Amount <br />2- <br />3. <br />4. <br />5. <br />Additional dates/amouats 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 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 - <br />Quarter 2 <br />Quarter <br />�rc <br />/ - <br />S <br />January --J March <br />April --> June <br />July --> September <br />October --> December <br />end to: SAN JOAQUIN LOCAL H1:ALT11 DIS <br />LJGT 40 10/86 <br />TRICT <br />1601 E. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />