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r F eg <br /> ���51n <br /> INVENTORY RECONCILIATION ,IAN 5 5-5� <br /> QUARTERLY SUMMARY REPORT FORM PE LNVIIPONM RNPI SSR HEALTH <br /> � FW" <br />/Facility Name „ / ` fi 'li >a7C /c'E <br /> Facility Address: <br /> Telephone : )'2 C 3 "��� <br /> Person Filing <br /> / <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 / Amount <br /> 1 . <br /> 2. <br /> 3. <br /> 4. <br /> 5. <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 allowablelimits <br /> was Lueeto <br /> a leak the incident shall be reported to S .J .L . H . D . <br /> lth <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly su,ary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --> March <br /> Quarter 2 - April --> June <br /> -_�->._�escember <br /> Quarters--=- -- -- r <br /> Quarter 4 - October --> 1k:cem <br /> Send co: SAN JOAQUIN LOCAL HRAL11c DISI'KICT <br /> 1601 @ . Hare 11 on , P . 0 . Box 2(1(19 <br /> Scockton , CA 95201 466-6781 <br /> UC'1' 40 10/ 86 <br />