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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM EPLVIROME"TAL HEALTH <br /> 1 FERMIS/bERVICtS <br /> Facility Name: 1 G( Sinck+oln l CJD Tank r Size Product <br /> Facility Address: lJ40 F_ 0I V)rCV- <br /> c W) <br /> Telephone : aG„�- <br /> Person Fil ' <br /> Report Z/"✓ <br /> �1 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 :::.lump 13 of the laveatocy Reconciiiation Sheet) <br /> E] Inventory 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 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 I 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 /> a leak the incident shall be reported to S . .I 1— H , D . Environmental 1lcalt1i <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 �� K <br /> Qin rtcr 2 - April --> June <br /> 1� <br /> Quarter 3 - July --) Septemher 0 <br /> Quarter 4 - October --> Ikcemher IN <br /> Send to: SAN JOAQU IN LOCAL HEALTH DISIRICT <br /> 1601 E. . Hazt• 11 4m , 1" 0 R :.: 700'1 <br /> SLockt-on , CA '15201 1466, - 67b1 <br /> UI:T 40 10/ 86 <br />