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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name; Jackpot Tank t Size <br /> Product <br /> Faeility;Address: Regular_401g rhe zeP t nP 4 1 <br /> ?rem U L <br /> —Lodi_ CA 95240 412 10 000 U L Regular <br /> Telephone : (209) �1F9-5Asr <br /> Person Filing <br /> Report Joe Sanzo <br /> E] 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. (Ho in Colu® 13 of the Inventory Reconciliation Sheet) <br /> MInventory 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 as unauthorized (leak) release. �XLSX74RX�#$4F4XA :4�A <br /> kX7tR JCyXA�t7t74}7RX31X7#SX}}Ir1X$?1R1fb3� (Based on daily measurement ertor only.) <br /> List date. tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I AmounC <br /> 1. SEE ATTACHED INVENTORY CONTROL SHEET <br /> Z- —12ZvaLaa DENOTE VAR1AT7nNq ZXCZ rNG ALL014ABLE LIMITS. <br /> 3. <br /> 4, <br /> 5. <br /> Additional dates/amouocs shall be continued on a separate sheet of <br /> paper and attached_ <br /> If the source of the variation which. esceeded 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 Aad 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 I - January --) March <br /> Qaarter 2 — April --) June <br /> Quarter J — July --) sepcemhcr <br /> Qiartcr 4 — October --) 0kccmber <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISI-RIC1 <br /> 160L E . HaZeILf,n , P . O . 1cox 2009 <br /> Uc;T 40 10/86 Stockton , CA 95201 466 -678L <br />