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INVENTORY RECONCILIATION r <br /> QUARTERLY SUMMARY REPORT FORM ?CI 1 c) IDR 11 g <br /> Facility ame:N /aj�e/// � ENVIRWLE-1p,L HEALTH <br /> /o7 i U�jj)��.� _ Yank / <br /> Size <br /> Facility'Addresa: Com 7-1, <br /> �• z <br /> Telephone : �Zpq Q �OOO <br /> Person Filing ere <br /> Report <br /> ❑ I hereby certiry undo. PrOAICY of <br /> the above neationed facility were within ythe aallowableentolimitst all iryvarforatithisa for <br /> quarter. (No is Column 130f the Inventory 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 varincioa <br /> was not due to an unauthorized (leak) rel"se. (Yes is Column I7 of the <br /> Iaventory Reconciliation Sheet) '— <br /> List date, tank P, aad amount for all variations that exceeded the <br /> allowable limits. <br /> Date- Tank f Amouat <br /> 2. <br /> 7. <br /> 4. <br /> Swv' <br /> dacesjamouats shall be contiaued on a separate sheet of <br /> Paper and attached. <br /> If the eCUrce of the variation which- exceeded al'lowabie limits vas due co <br /> a leak the incident shall be reported to <br /> Within 24 hours aad an unauthorized release report submicced�nmcntal health <br /> The quarterly summary report shall be submitted within <br /> quarter. I$ days of the end of each <br /> Quarter 1 - Jaouary --) march <br /> Q'Aartcr Z - April --> June <br /> Quarter ) - July --> Scptcmbr.r <br /> Quarter 4 - October --) I)rcember <br /> Send co: SAN JOAQUIN LOCAL. HEALTH UIS'1'R [C•1' <br /> 1601 E . I:aze11 ,111 , P .O . ISox '1.009 <br /> Stockton , CA 95201 466 -67b1 <br />'(;1' 40 10/86 <br /> i <br />