Laserfiche WebLink
• <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Facility Address: 351-�b�M+4 <br />Telephone: <br />Person Filing_ <br />,�� ,� n <br />Report _ <br />Awd�D <br />NT A� HEALTH <br />ENVIRO�E' VICES <br />� FR[Jill /SER <br />Tank a>E <br />Size <br />Product <br />I Z <br />KK <br />jz <br />T_>c! <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 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) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank i, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank f Amount <br />2. <br />3. <br />4. <br />5. <br />Additional daces/amounts shall be continued on a separate sheet of <br />paper and attached. <br />If the source of the variation which.erceeded al -towable 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 - January --> March <br />Quarter 2 - April --> June <br />Quarter 3 - July --> Septemher <br />Quarter 4 - October --> December <br />Send co: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. luau 1 t-0►n , P.O. BOX 2009 <br />Stockton, (:A 95201 466-67b1 <br />UCT 40 10/86 <br />