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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Faeility Name: Jackpot W'. <br /> ct <br /> Fadlity,Address; 4(rl c rho, kee . ar_TodiCA 95240anp <br /> Telephone : (,(19) F9_SFS,, lar <br /> Person Filing <br /> Report Joe Sanzo <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 /> 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. l�'2[}(1ti}}g ' <br /> � �[X tx74747C7G2X}t I� {$}17;t�}) (Based on daily measurement error only.) <br /> List date. tank f, and amount for all variations that exceeded the <br /> allowable limica- <br /> D_te Tank f Amount <br /> 1• SEE ATTACHED IWELILY CO *RTOi, cryFrT <br /> 2. A.4TnRTSKS <br /> --.�,.�,.... DENOTE L'nu7aTmue rvrranrgG ALLO[TABLE LI;IZTS. <br /> 3. <br /> 4. <br /> 5. <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 allowableLiito <br /> Envi <br /> a leak the incident shall be reported to S .J . L. H . D. <br /> Within Z4 hours and an unauthorized release report submittedonncntal lical[h <br /> limits was due <br /> The Quarterly summary report shall be submitted within IS days of the end of each <br /> Quarter. <br /> Quarter I - January --) March <br /> QQIartcr 2 - April --) June <br /> Quarter J - July --) Sep[cmh��r <br /> Quarter 4 - October --> <br /> Dcccmhcr <br /> ,end Ca° SAN JCAQUI:+ LOCAL. HEALTH UIS-1'1ZIC'1' <br /> 160L E . HaZCIL011 , P . O . fins 1009 <br /> ILCT 40 10/86 SLockton . CA 95201 466 -6781 <br />