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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Mame: 7Z rank f Site. Product <br /> / eJ�- <br /> FaciIity�'Addreaa /Z/ G .S i:JGTdr✓. (�'• <br /> 7. <br /> Te lephone : <br /> Person Filing <br /> Report <br /> QI 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 /> Laventory 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 Column13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank /, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date rank Amount <br /> 5. <br /> Additional dates/amouatx shall be continued on a separate sheet of <br /> paper and attached. <br /> It the source of the variation which. exceeded allowable limits was due to <br /> a lcxk the incident :hall be reported to S „J L.H ,D, Environmenta L Health <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall by submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) March <br /> Qviarter 2 - April --> June <br /> Quer_ er 3 .July --) September rT� j <br /> Quarter - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH UIS'l'KICT <br /> 1601 E . l{ar_e I Lcu1 , P .O . Box 2004 JAN <br /> Stockton , CA 95201 466-6761 ENVIROMENTAL HEALTH <br /> L1CT 40 10/ 86 FERWT/SERVICES <br />