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r1 <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Jackpot Tank f Si - Product <br /> _ u r <br /> Facility_,Add ress: 401 S. CherokPp T,anp &11 4,000. Prem U L <br /> Lodi_ CA 95240 412 10,000 U L Regular <br /> Telephone : (209) 16q-5654 <br /> Person Filing <br /> Report Joe Sanzo <br /> I 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 D 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. �XIIXX�CRX4; 41td?�XAYR4Y <br /> 3TRXRR1iAX�LX�Y7C74}IICI[]17L}1xX14RX$}lxlf�3� (Based on daily measurement error only.) <br /> List date, tank i, and amount for all variations that exceeded the <br /> allowable limi[s- <br /> Date Tank It Amount <br /> 1. SEE ATTACHED INVENTORY CONRTOL SHFFT <br /> 2- ASTFL2ISKS DRNOTF VARTATIONG EXCEEDING ALLOWABLE LIMITS. <br /> J. <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 allowable limits was due to <br /> a leak the incident shall be reported to S .J .L.H . D. Enviror=ental licalth <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 /> Quarter 1 - January --) March <br /> Quarter 2 - April --) June <br /> Quarter J - July --> Septcmhcr <br /> Quarter 4 - October --> Gl ccmber <br /> :icnd to: SAN JOAQUIN LOCAL. HEALTH OISTRLC1' <br /> 1601 E . I:azcltnn , 1' .0 . Rox 2009 <br /> UCT 40 LQ/HG Stockton , CA 95201 466 -6781 <br />