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Facility Name: <br />*ENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />C] L 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 ReconciIiacion. Sheet) <br />Inventory variations exceeded Che'alLowable limits for this quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to as unauthorized (leak) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, tack f, and amounc for all variations that exceeded the <br />allowable unties. <br />Date Tank Amount <br />2. <br />3. <br />4. <br />5. . <br />Additional daces/ vacs shall be continued on a separate sheet of <br />paper and attached. <br />Lf the source of the variation which.exceeded allowable limits was due to <br />a leak the incident shall be reported to S.J.L.N.D. EnvironwentaL Health <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.xrtcr t - January --> March <br />Quarter 2 - April --> June <br />Quarter l July --> Srptcmb4:r <br />Quarter 4 - October --> t}--ce ber <br />Send co: JOAQULN LUt:At. HEALTH UI;i'1'K1C1' <br />O 1 F ilaze 11 cat . 1' .0 . Ilam 2009 <br />� CA 95201 466-67bl <br />Ll(;T 40 10/86 �� <br />f. -.A <br />