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Jia <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM ST I3,R7 <br /> / _ N'ENTAL HEALTH <br /> Hasse:Facility Nae: EG /f�F_ Fo21� Tank I Size ERr,ft LICE <br /> x0 [ G¢5 <br /> Facility Address: ioY� s �ilFPD�Er v ac u�s:F piG <br /> ,Co/Ji " �//ciC 9Tx9'O <br /> Telephone : 33y ls�n <br /> Person Filing <br /> Report �J-C-r-5� uF_ en E2 <br /> I hereby certify under penalty of perjury that all inventory variations for <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 this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> vas not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank i, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amouats 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 /> X Leek 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 /> Qiarter 2 - April --) June <br /> Quarter J - July --) Septcmber <br /> Qaarter 4 - October --) Occcmber <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . HaZeIL(W . P .O . Box 2009 <br /> SLockton . CA 95201 466 -6781 <br /> UG1' 40 10/ 86 <br />