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INVENTORY RECONCILIATION <br />QX QUARTERLY SUMMARY REPORT FORM <br />Facility Na"'C: <br />_� '!" 922 C 0 <br />!Facility Addre..: �_/ ��—/0 � <br />Telephone: t7 <br />Person Filing <br />Report a <br />U 41 <br />JUL 10 1999 <br />'1 V!RC "gMENTAL HEALTH <br />I3Cn AartSFP\/I( P, - <br />faI hereby certify under Penalty of variations <br />the above menCioned facility were withinytheaallowableelimitsntory foe thsfor <br />quarter. (No in Colum= l3of 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 variation <br />was sot due to as unauthorized (leak) release. (Yes is Column l3 of the <br />Inventory Reconciliation Sheet) <br />LisC date, Caak /, and amount for all variations that exceeded the <br />allowable li-ics. <br />Date Tank i Amount <br />z. <br />3. <br />4. <br />5. <br />A,'diCtoaal datcs/amouots shall be contioued on a separate sheet of <br />paper and accactied. <br />if the source of Ctte variation vhich cXcecded at -lovable limits was due to <br />a leak the incidcnc shall be reported to S.J.L.H.D. Environmental ttealcPt <br />►rithin 24 hours and an unauthorized release report submicced. <br />me quarterly sua,mary report shall br K%IbmC <br />quarter. cced within 15 days of the end of each <br />`"r - January <br />Qjartr <br />Apra' <br />mrC-r - Jul <br />Y <br />QtarCrr 6 - October --> <br />kcrmbcr <br />Send to: SAN JOAQU I N 1,0CA1. 111rA1,Tli U I STR I C'1' <br />1 60 1 E. 1:,7zc• 1 t tin . I) .O . littx I()t!`J <br />40 t�/fi(� SLockcon. CA `15201 466-61b1 <br />� <br />