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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Jackpot Tank I Sixe Product <br /> Facilit Address: u r <br /> .. 408 10 000 <br /> y' ., . _ 401 S ClierokPe T.nne 1 Prem U L <br /> Lodi_ CA 95240 412 10,000 U L Re ular <br /> Telephone : f909i 16Q-9654 <br /> Person Filing <br /> Report Joe Sanzo <br /> ElI 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 Reconciliation Sheet) <br /> aInventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was DOC due to an unauthorized (leak) release. fu fAft <br /> I4R14R�14X$XF9Glt74?}ICXXA�XI4YlXlf[7� (Based on daily measurement error only.) <br /> List date. tank /, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank E Amount <br /> 1. SEE ATTACHED INVENTORY CONRTOL SHEET <br /> Z- ASTERISKS DENoTR VARIATIONS EXCEEDING ALLOWABLE LIMITS. <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 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 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) March <br /> Qvarcer 2 - April --) June <br /> Quarter 7 - July --) September <br /> Quarter 4 - October --) December <br /> Scnd Co: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160L E . HazelLon . P . O . Rox 2009 <br /> UCT 40 10/86 SLockton . CA 95201 466 -67bl <br />