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01V <br /> Y IN1(ENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REKIRT FORM <br /> Facsl,it7 Name: ,�l=�f�/�-•.S /��,n .-j'/'�I Tank � _..•.._... <br /> S�..sex Product <br /> Facilitr4ddress: ,$� / CQtiiSL= <br /> /�/i�; �. <br /> Telephone : -!;]L d 41" <br /> Person Filing + <br /> Report !-�A( <br /> I hereby certify under penalty of perjury that all inventory variations for* r-. . <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (No in Column 13of the Inventory Reconciliation Sheet) , <br /> ElInventory variations exceeded the allowable limits for thio quarter. I <br /> hereby certify under penalty of perjury that the source for the varistio� ;,; ` <br /> was not due to an unauthorized (leak) release. (Yes in Colemta rjg0f• c' 1 <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, sad amount for all variations- that exc4'eded the <br /> allowable limits. s ' <br /> Date Tank f Amount <br /> 2. <br /> 3. <br /> . <br /> Additional dates/amouats shall be continued on 4 separaCe sheet of <br /> paper and attached. <br /> If the source of the variation which. exceeded al-lovable limits was due to <br /> a leak the incident shall be reported to S .J .L.H . d'. Eavirormental "Health <br /> within 24 hours and an unauthorized release report submitted. ; <br /> The Quarterly summary report shall be submitted within l5 ;days of the cad of each <br /> Quarter. r <br /> Quarter I - January --) Hirch <br /> Quarter 2 - April --> JunC <br /> Quarter 3 - Ju.hy --> September _ <br /> ' Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN WCAL HEALTH H'STH-ICI' <br /> 160L E. haze l L O . P .O . Box• 1.Q.U. " <br /> Sc:ockton , CA 95201 466 '67£si <br /> Ur,T 140 10/ 86 - =a <br /> /�'f/o <br /> 7c C�—c�, , 'y 7-6 L _ .. _.. <br />