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t <br /> INYENTORY RECONCI <br /> LIATION JAN 17 '108 9 <br /> QUARTERLY SUMMARY REPORT FORM <br /> [i'v' �LHEALTH <br /> Facility Name; I - 9� PEf VICES <br /> -�/�P�� <br /> FaciliC rank f Size <br /> . y•Addreas: QO Product <br /> Telephone : �9 9y?_S�o <br /> Person Filing q <br /> Report ,Y�C/ )rn75` <br /> ✓B/ I hereby certifyunder exalt of <br /> the above Penalty Perjury that •11 inventory variations for <br /> (No facility were within the •lLovable limits for this <br /> quarter. (No is Column 13of the invcatory Reconciliation Sheet) <br /> ❑ inventory variations <br /> hereby certify under exceeded the allowable limits for this quarter. j <br /> Penalty of Perjury that the source for the variation <br /> was sot due to an unauthorized (leak) release. (Yes is Columa 13 of the <br /> Inventory Reconciliation Sheer) — <br /> List date, tank /, and amount for all variations chat exceeded the <br /> allowable limits. <br /> Date rank E <br /> Amount <br /> 1. <br /> 2. <br /> }. <br /> S. <br /> Additioaal dates/amounts shall be continued on a separate sheet of <br /> Paper and attached. <br /> If the source of the variation whichexceeded allowable limits was due to <br /> A leak the incident shall be reported to S .J .L.H . D. Environmental licalth <br /> Within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be Rubmitted within <br /> quarter. IS days of the end of each <br /> Quarter I - Jaousry __) March <br /> Qaarccr 2 - April --> June <br /> Quarter I - July --) Scptcmher <br /> Quarter 4 - Octobcr --> (kccmbcr <br /> Send to: SAN JOAQUIN LOCAL HEALTH DIS'1'HICT <br /> 1601 E. IIa7.Cl1tu1 , P .O . Ilox 20O') <br /> 0 LQ/HG Stockton , CA 95201 466 -67bi <br /> 11' 4 <br />