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1� <br />INVENTORY RECONCItI,ATI _ <br />APS 1 � 1 <br />QUARTERLY SUMMARY REPORT FORM- <br />EN�► , <br />ViR a4t L MEAL IH <br />F'aciLlty It 1;1wws ".,:Iq. ors— Inc Tank 8 Sate Product <br />Roy g <br />racilitl4ddres: 1.3'WXttlmnLn eR <br />c1 r t ai irzi 3 lSt�.1 em JP S <br />Telephone: � wT <br />Person Filing <br />Report .+ ,.. �. <br />X 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 Columa 13of the laveatory Reconciliation Sheet) <br />Inventory variations exceeded the,allowable limits for tibia quarter. I <br />hereby certify under penalty of perjury that the uorce for the variation <br />was Got due to as unauthorized ('laeak) cele asae. flies in Column 13 of the <br />inveatory Reeonciliatloa Sheet) <br />Gist dame# tank fr and amount for alt variatiows that exceeded the <br />' <br />allowable limits. <br />Bate 'Tank Amount <br />v41( <br />a <br />Max q0 3 <br />4® <br />sa <br />Additional dates/ unts shall be cou icued oa *-separate sheet of <br />paper and attached. <br />It the source of the variation which. exceeded all able limits was due to <br />a teak the incident shall be reported to S'.1 L.1$ . U, EnvironaientaL Health <br />. <br />Within 24 hours and an unauthorized release report submitted. <br />The quarterly suamary report shall be subwitted within 15 days of the end of each <br />�u.mrcer: <br />Quarter 1 - Jaouary March <br />Janes <br />garter 3 July --> September <br />Quarter 4 _ October --) December" <br />Sin to: SAN JOAQUI i Lt)tAL HEALTH 1}IS°t"RIOT <br />1601 E. Hare l L ost m 13 . G" . ROX 2009 <br />Si,: sckt,con , (:A:95201 466-67 1: <br />p'�J. <br />@@:gF /..A11,0/h6 <br />