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V�5 <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />iaeility Name: eAL/FDRA 117 A1101WXY 170MOt <br />iaeility�Addreaa: 38S[uFSTCR�1NTt/�u,r- <br />-Frioey en 95376 <br />Telephone: 201 - 83S- 89ZO <br />Person Filing <br />Report /1.1). M11L/C14N ''*1667- <br />R E <br />r a� <br />APR 1 2 7"1 <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 Colusm 13 of the Inventory Reconciliation Sheet) <br />E] Inventory variations exceeded the allowable limits for thin quarter. i <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to ac unauthorized (leak) relebae. (Yea in Coluan 13 of the <br />Inventory Reconciliation Sheet) <br />List dates tank is and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank F <br />2. <br />3. <br />4. <br />S. <br />Amount <br />Additional dates/:,,nuats shall be continued ou a eeparzte sh<_et of <br />paper and attached. <br />If the source o: the variation vhich.exceeded allowable lieits wzZ due to <br />a leak the incident shall be reported to S.J.L.H.D. Envirorur,:nta,l Health <br />within 24 hours and an unauthorized release rcpart subaitted. <br />The quarterly su�cy report shall be submitted within 15 dzyz of the end of each <br />quartet. <br />`F 9 O <br />Quarter 1 - January March <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />160L E. llazelLain, P.O. Box 2009 <br />Stockton. CA 95201 466-67b1 <br />--) <br />aartec - April --> June <br />Quarter ) - July --) Scptcmhcr <br />Quarter 4 - October --) December <br />iGT 40 10/86 <br />II <br />iGT 40 10/86 <br />II <br />