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C <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: { .1e.. <br />facility <br />Facility Addros*t ✓`�� �T�.�. <br />Telephone: z. - ,C 7 <br />Person Filing <br />Report <br />RECEiNtu <br />L 15 1991 <br />ENVIRONMENTAL HEALTH <br />PER IT/SERVICES <br />I hereby c4Rtify under penalty of perjury that all-inv+antary variation* for <br />the above mentioned facility were within the allowable limit* for this <br />quarter. (No in Columa 13 of the Iaveatory Reconciliation Shtet) <br />[] Inventory variations Sxceeded the allowable limits fer this quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />W44 not due to an unauthorized (leak) release. (Yes is C014M 13 of the <br />Iavegtory Reconciliation Sheet) <br />List data® tank i, rad amount for 411 variatiaae that exceeded the <br />allowgple limits. <br />Date Tank Amount <br />1• <br />2. <br />3. <br />4. <br />S. <br />e <br />Additioasl date*/,amounts shall be continued on a separate sheat of <br />p*par and attachcd. <br />If the sourcx'of tho variation which. exceeded allowable liwits MAa dun to <br />t leak the incident shall be reported to S.J.L.H.D, RaviropmataL Health <br />Within 24 hours and on unauthorized release report submitted. <br />The quarterly sumwmacy report shall be submitted within 15 flays of the end ofeach <br />quarter. <br />Quarter 1 - Jaauar --> March <br />rter 2 - - una • <br />Quarter 3 - July September <br />Quarter 4 - October --> Decvmber <br />Send Co; SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 R. Hazelton, P.O. Box 2009 <br />Stockton, CA 95201 466-6781 <br />UCT 40 10/86 <br />