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• <br />. INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Jamar service <br />Facility Address: 4075 Enst- Malu <br />Telephone: 462-8707 <br />Person Filing <br />Report H/� ��L!/72 <br />uI hereby cgrFify under penalty of perjury that all. inventory variations for <br />the above mentioned facility were within the allowable liwits for this <br />quarter. (No in Column IJof tht Inventory Reconciliation Shget) <br />C <br />Inventory variations exceeded the allowable limits for this quarter. I <br />hereby certify under penalty of perjury that the sourcC for the variation <br />was not due to an unauthorized (leak) release. (Yes in Column I] of the <br />Iavegtory Reconciliation Sheet) <br />List datev tank f, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank f Amount <br />2. <br />3. <br />4. <br />S. <br />"4itional dates/amounts shall be continued on a separate sheet of <br />paper and attached. <br />If the source of the variation whicla exceeded allowable Rlimittswnsal health <br />to <br />a leak the incident shall be reported to S.J.L.I1.D• <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 - January --> Narch <br />Quarter 2 - April --> June <br />Quarter I - July -,-> September /�� , <br />- c o e -- •cem er /`i - <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton, P.O. Sox 2009 <br />Stockton, CA 95201 466-6781 <br />UGT 40 10/86 <br />