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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Tank 1 Stat I Product <br /> / O ooJ ,QccnZ <br /> Facility 93 ��0 ✓z ?�*6 ° o°o <br /> 7r/L��a 9S� fu 3 v <br /> Telephone : 4:2e9) 33 4-.49G7 q <br /> Person Filing <br /> Report ( �' ` <br /> 'K Nar Qunf��..�£O Ws H�5£E S�iv_�'E RfFaRY <br /> QI 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 13 of the loventory Reconciliation Sheet) <br /> 12-1'�Iaveotory 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) rji. ,(1[ <br /> -� �.mc..-t ' RPS .oAny <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank 1 Amount <br /> S- <br /> -7, <br /> -7, 3/9 a 9s <br /> 3. 3 <br /> 3flo a � ° <br /> 4. A/9 1 <br /> 5. 4/3 / _ 30 <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 due to <br /> a leak the incident shall be reported to S .J .L.H.D. Environmental Health <br /> within 24 hours and an unauthorised release report submitted. <br /> The Quarterly summary report shall be submitted within 15 days of the end of each <br /> Quarter. <br /> CJ "' ;a, lljij <br /> atter 1 - January --1 March /`I89 <br /> i <br /> Quarter 2 - April --> June APR y x. 19 <br /> Quarter 3 - July SeptcmAcr 3U <br /> Quarter 4 - October --> December `-NVIROME:yTAL HEALT <br /> Send to: SAN JOAQUIN LOCAL HEALTH OIS1'HICT FERrWiT/SERVICES H <br /> 1601 E. liazeli (m , I' .O . Rnx 100 ) <br /> Stockton , CA 95201 466-67b1 <br /> UGT 40 10/86 <br />