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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: �� FAA r-1\ —Tank—V— Size Product <br /> Facility Address: -D\ WQJW—' U <br /> Telephone :- Z -201 <br /> Person Filing <br /> Report � � l(V��v\y�pyar <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 /> 0 Inventory variations exceeded the allownble Limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank /, and amount for all variations that exceeded the <br /> allowable limits. <br /> Y: x <br /> Date Tank / Amount <br /> 2. APR 9 ;929 <br /> 3. i_NVIRONMENTAL HEALTi <br /> PE t;'dIT/SERI -,"!CES <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate `sheet of <br /> paper and attached. <br /> If the source of the variation which exceeded allowable limits was doe to <br /> leak the incident shall be reported to S .J .1...11. D. r•.nvirotimental Health <br /> Within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within 15 Mays of the end of each <br /> quaAer. <br /> Quarter 1 - January Narch ojoio <br /> Qaarter 2 - Apr tl <br /> Quarter 3 - July --) September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . 11aze 1.Lo�n , P .O . Rox 7.009 <br /> SLockLon , CA 95201. 466-6781 <br /> UG,r 40 10/86 <br />