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N1 <br /> INVENTORY RECONCILIATION I� ,1111 51988 <br /> QUARTERLY SUMMARY REPORT FORM ENVIROMENTAL HEALTH <br /> FERMIWSERVICES <br /> EacLL ty Names 14 ct R4 S� .v��;'� Task 0 Stse <br /> P[oduct <br /> [acllity Address: i, !Z .e ASN <br /> Telephone : <br /> Person k-LLLng <br /> Report PV F <br /> L heceby 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 13 of the inventory Reconciliation Sheet) <br /> ❑ Imvemtccy variatioas 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 as unauthorized (leak) rele'aae. (Yes in Column 13 of the <br /> I lnveatoey Reconciliation Sheet) I I <br /> List date. taak 1. .and sasount for all variations that exceeded the <br /> Allowable limits. <br /> Date Tank ! Amount <br /> 2. <br /> J. <br /> 4. <br /> 5. <br /> Additioosl dates/amounts chill be continued on a separate sheet of <br /> paper and actachcd . <br /> If Che source of the vac[a( ion s1%101 rxce,ded allowbte limits vas due CO <br /> . luC <br /> k `Chc tnsdcn( shall be rrpsr(cd [n S .J . 1. . Rnm <br /> D . EvironcnCal Ilcal ( h <br /> "Chin 24 hours and an unauthor, trd relrasr report subeicced. <br /> Llsc Quarterly sum ry rcporc shall be submi (Ced within 15 days of the end of each <br /> quar(rr . <br /> QuartCr I - January <br /> �aarcer 2 - April --) Jun.. <br /> Quarter 3 - July --) septemher <br /> Q•.artcr 4 - October --> D'Cemher <br /> Send CO: SAN JOAQUIN LOCAL HEALI'li DISTKICT <br /> 1601 E . Ha•zeli4u1 , 1' .0 Ro x 20w) <br /> S(ockcon . CA 75201 466-67b1 <br /> U1;1' 40 10/86 <br />