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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />FaciLity Name: 01AP IVIA11, 11174�U- <br />114CJ1kty4ddress: IW 71 IV hl&IY <br />Telephone: <br />Peraon ELLLE18, <br />Report <br />X. hereby certify under penalty of perjury that all <br />the above lbe-Utioned inventory variations for <br />quarter. facility were within the allowable limits for this <br />(—HO in Column 13of the 1,011catory Reconciliation Sheet) <br />r -1V <br />U Inventory Variations exceeded the Allowable limits for th, <br />hereby certify under Is quarter. I <br />was not due salty Of Perjury that the source for the variation <br />Inventory CO An unauthorized (Leak) release® (Yes in CoLutmmD of the <br />Reconciliation Sheet) <br />List date, tank #0 and amount for all variations <br />Allowable limits. chat exceeded the <br />Date <br />Tank Amount <br />---------- <br />3. <br />4. <br />5. ------ <br />---------- ------- <br />Additional Bates/ amoants shall be <br />Paper and attached. continued On a separate sheet of <br />Lf the <br />source Of the variation which* "ceeded <br />4 leak the incident shall be reported to allowable Limits was due to <br />Within 24 hours and an unauthorizedS - J E <br />nvirotaL HcaIth <br />reLc3sereport submtted. <br />The quarterly $um-4CY report shall be xubmitCed within 15 days of the end of each <br />Quarter. <br />Quarter 1 - J""rY March <br />QUArter 2 - April June <br />Quarter 3 - July September <br />Quarter 4 - October 0'.-cember <br />Send Co: SAN JOAQUIN 1.0(:AI® HEALTH <br />1601 I".'. Hazelton, 1).0. 1j().,< 2()(),) <br />40 10/86 SLockton, CA 95201 46o-67bi <br />