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0 <br /> I .,YENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM JAN 191939 <br /> ENVHR0f-110"1ENTAL HEALTH <br /> Facility Name: Tank at Size oduc <br /> Facility Address: <br /> Telephone : <br /> Person F in <br /> Report <br /> EJI 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 Coluam 13of 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 /> wax not due to as unauthorized (leak) release. (Yes in Coluam 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank /, and amount for all variations that exceeded the <br /> allowable limits_ <br /> Date Tank f Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper znd attached. <br /> If the source of the variation which. exceeded allovable limits was due to <br /> a leak the incident shall be reported to S .J . L . H . D . Environmental 1lealth <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 /> Qu';.rter I - January --) M.irch <br /> Q•lartcr 2 - April --> June <br /> Quarter 3 - July --> Septemher <br /> Quarter 4 - Octobcr --> fk.ccmbcr <br /> Send to: SAN JOAQU IPS LOCAL HEALTH U i STR I C'1' <br /> 1601 !" . Hazc 1 t (m , P - 0 - M)x 1009 <br /> Stockton , CA 95201 466-6161 <br /> UCT 140 10/80 <br />