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� 0 <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM JAN 181989 <br /> IN iRCf`,".;' IN At HEALTH <br /> Facility Name: �� i 1tiKS �rJ� :� in�1Cd�11 It��_i! Tank IF Size <br /> 77) <br /> E� <br /> Pacility Address: 1 . ` - - �J+ 000 F E- <br /> i A0 On r C ,t g_ <br /> Telephone : (593CL S15" <br /> Person Filing <br /> Report <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 13 of the Inventory Reconciliation Sheet) <br /> 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 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank # Amount <br /> 3. <br /> 4. 11- I - B j <br /> s.. <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 unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within IS days of the end of each <br /> quarter. <br /> Quarter 1 - January --> March <br /> Quarter 2 - April June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October December <br /> Send to: SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 1601 E . Hazelton , P . 0 . Box 2009 <br /> Stockton , CA 95201. 466-6781 <br /> UGT 40 10/86 <br /> �� o' � � <br />