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IMYENTORY RECONCILIATION • <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: �Qf Oy � �,�jp^/ Yank I Size Product <br /> �� l� t <br /> Facility o?o2G/ Gy GUASh/.✓c7eJ_r <br /> Telephone :�.?p�/ 95/>>-o25�G- ft3�0 <br /> Person Filing <br /> Report <br /> ❑ I hereby certify under penalty of perjury that all inventory variations for <br /> the above wationed facility were within the allowable limits for this <br /> quarter. (No in Column 13of the Inventory Reconciliation Sheet) <br /> u , 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 Col, 13 of the <br /> Inventory Reconciliation Sheet) <br /> List datev tank Of and amount for all variations that exceeded the ` <br /> allowable limits. <br /> Date Tank ! Amount <br /> 1. ��o ��-. 0 . <br /> 2. <br /> 3. <br /> 4. S/7 // 5z <br /> Additional dates/amounts shall be continued an 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 IS days of the end of each <br /> quarter. <br /> Quarter I Januar --> March <br /> arter 2 April --> Jun <br /> arcer 3 - July —) Scpccmhcr <br /> Quarter 4 - October --> December <br /> Sena cm_ SAN JOAQUIN LOCAL HEALTH Dis-rRICT <br /> 1601 E. 14azelLun . P .O . Box 2009 <br /> SLockton . CA 95201 466-6781 <br /> UGT 40 10/86 <br />