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0503 ,8 <br /> AF, 19 <br /> INVENTORY RECONCILIATION to <br /> QUARTERLY SU.w A R F P 0 R T FORM �IIR MENTA�C <br /> �' EN �SZ tSERv <br /> FaciLicy Hone <br /> S 7Rim <br /> Facility Address• /Je"/ <br /> Z/ PT71 J <br /> Telephone : <br /> Person <br /> Report <br /> ❑ I hereby certify under penalty of perjury Chat all inventory variations for <br /> the above eencioncd facility were within the allowable limits for this <br /> quarter. (Ho in Column IJof the lavencocy 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 as unauthorized (lesk) releiae. (Yes in Col— D of the <br /> Inventory Reconciliation Sheet) <br /> List dace, tank 1, and azaounC for all variations that exceeded the <br /> allowable limits- <br /> Date Tank 1 AmouaC <br /> 1. <br /> 2_ <br /> 7. <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- exceeded al,lc n ble limits vas due to <br /> a leak Che incident shall be reported to S .J . L. H . D. Env <br /> in <br /> romental Health <br /> MiChin 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be Fubmitced within 15 days of the end of each <br /> quarter. <br /> Quarter 1 - January --) March <br /> Quarter 2 - April --> June <br /> Quarter ) - July --> sepccmher <br /> Quarter 4 - Occober --> Ilecember <br /> Send cot SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . !!�zcll n , P . 0 Box 2009 <br /> ',ICT 40 10/ 86 SLockcon . CA 95201 466 -6751 <br />