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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Q LU 14 SQA ' 1z5 M*PT <br /> _ roducPAC. ity Address: 5 EG9D iL RAIA) o r L <br /> ,Telephone : Zoy_ 599- 225/ <br /> Person Filing <br /> Report 62C-42--� ®� <br /> ', <br /> I hereby certify under penalty of perjury that all inventory variations <br /> the above mentioned facility were within the allowable limits for this for <br /> quarter. (No in Column 13 of the Inventory Reconciliation Sheet) <br /> QInventory variations exceeded the allowable Limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> vas not due to an unauthorized (leak) release_ (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f A=uat <br /> 1_ <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amouats 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 <br /> quarter . IS days of the end of each <br /> Quarter I - January March <br /> Q+larter 2 - April --> Jude 9 <br /> CQ <br /> Quactec 3 July --> September <br /> aacter 4 - October --> December <br /> � en`i to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton , P . O . Box 2009 <br /> UCT 40 10/86 Stockton, CA 95201 466-6781 <br />