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INVENTORY RECONCILIATION \ ✓ � g a A q <br />QUARTERLY SUMMARY REPORT FORM FEB 11989 <br />raeiltty Nage: 09L/F6RAJil9 A1101WXY 17,4 106 <br />r,eilier,Adereas: 38StuFSTGAtAnirtiAvr . <br />'1'R�4['Y CA 9S37L <br />Telephone: 201 - 835- 89ZO <br />Person Filing <br />Report W.Gfl, /n/11/6/9N 'YGLL <br />ENv62„N..i1NTAL HEALTH <br />prl?vi I ! SFR'JK'FS <br />Tank I <br />Size pcoduct <br />19 I hereby certify under penalty of perjury that all inventory variations for <br />the ab-ove saenticned fzcility were within the allowable limits for this <br />quarter. (No in Columa 13 of 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 />was not due to ac unauthorised (leak) release. (Yes in Coluam 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank /s and amount for all variations that exceeded the <br />allowable limits. <br />Date <br />1. <br />2. <br />3. <br />4. <br />5. <br />Tank 0 Mount <br />Additional daces/a::.ounta shall be continued ou a e,:parste slv_ct of <br />paper and attached. <br />If the source of the variation whicN.exceeded allow-ble lieits wan due to <br />it leak the incident shall be reported to S.J.L.H.D. Environ:ents,l lfc lch <br />within 24 hours and an unauthorized release report sub"itted. <br />The Quarterly &u,—ry report shall be submitted within 15 dayi cf the end of each <br />quarter. <br />Quarter I - January --) March <br />Quarter 2 - April --> June <br />July --) Scpcember <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazcicim, P.O. Box 1009 <br />Stock Con. CA 95201 466-6761 <br />iCT 1.0 tO/86 <br />