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so <br /> IHYENTORY RECONCILIATION <br /> QUARTERLY SU ARY REPORT FORM <br /> >F r <br /> Facility Name: 1, E1�1VE�C °>i:VTAL HEALI}-1 <br /> ✓ C Z Tank Sir <br /> Product <br /> Telephone <br /> Person Filing <br /> Report — <br /> �� S `GL <br /> L I hereby certify under Penaltyf <br /> the above °'coperjury that all inventory variations For <br /> mc'Oncd ;rdcility were within the allowable liciits for this <br /> quarter, (No in Column 13of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable limits for this quarter. <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due Co an unauthorized (leak) releise. is Coluaa� l3 of the(Yes <br /> Inventory Reconciliation Sheet) yes <br /> List date, tank i, and Ymount for all variations that exceeded the <br /> Allowable limits. <br /> Date Tank I <br /> Amount .. . <br /> 1. <br /> Z. <br /> 3. <br /> 4. <br /> S. <br /> Addi[ioaal daces/amounts shall be continued on a separate sheet of <br /> Paper and attached. <br /> If the aource .of the variation which. exceeded at-lowable <br /> a leek the incident shall. blimits was due to <br /> e reported to S -J • L.H . D. Environmental <br /> within 24 hours and an unauthorized release report submitted. llcalth <br /> The quarterly sumaary report shall be Aubmitted within IS days of the end of each <br /> 9uarter. <br /> Qti,arCcr - January --> tlzrch <br /> }aCrCer <br /> April --> June <br /> Quarter 3 - July --) Septemh4:r <br /> Quarter 4 - October --) December <br /> Scnd to' SAN JOAQUIN LOCAL HEALTH UIS'rH1c'1' <br /> 1101 I: . I{, r.eltcEt� , E' .© . )()()`) <br /> 1,0 10/ 86 Stockton , CA 99201 466-6781 <br />