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'INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility. Nam: �✓,c�te, �ip},.'� <br />scilstyWdresss /�1> d / Lo <br />to � e-,, 2p., CA 25 3.30 <br />Telephone: (2 -eft J 6) 3 - :�) 3 <br />Person Filing <br />Report �✓�� %h,a <br />I hereby certifyunder penalty pe y o f perjury that all inventory variations for <br />the above mentioned facility were within the alLowable limits for this <br />quarter. (No in Column 13 of the Inventory Reconciliation Sheet) <br />QInventory variations exceeded the allowable limits for this quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to an unauthorized (leak) release. (Yes in Col 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tack f, and amount for all variations that exceeded the <br />allowable limits. <br />Date lank Amount <br />2. <br />3. <br />4. <br />5. ENV1Ru'Vr--!,g1AL HEALTH <br />F RFAIT/SERVICES <br />Additional dates/amounts shall be continued on a separate sheet of <br />paper and attached. <br />If the source of the variation which. exceeded allowable limits was due: to <br />a leak the incident shall be reported to S.J.L.H.D. Environmental Health <br />within 24 hours and an unauthorized release report submitted. <br />The quarterly summary report shall be submitted within 15 days of the end of each <br />quarter. <br />Quarter I - January --> March <br />L -Quarter 2 - April --> June <br />Quarter 3 - July --> Septcmhc^r <br />Quarter 4 - October --> Gecember <br />Send to: SAN JOAQUIN LOCAL HEALI-H DIS-1-RICT <br />160L E. Hazelton, P.O. Box 2009 <br />Seockton, CA 95201 466-6781 <br />LILT 40 10/86 <br />