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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Jackpot Tank I Size Produce <br /> FacilitAddress: r <br /> 408 <br /> y _ _ 401 S. Ch�rokaa T r a411 P m U L <br /> Lodi_ CA 95240 412 10,000 U L Re ular <br /> Telephone : _ <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. (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 /> was not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank i, and amount for all variations that exceeded the <br /> allowable limics_ <br /> Date Tank 0 Amount <br /> 1. SEE ATTACHED INVENTORY CONRTOL SHEET <br /> 2. --AZT ,&1a $ DENOTE. VARTATInNc 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 /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTIi DISTRICT <br /> 160L E. Ilazellon , P .O . lion 2009 <br /> Seockton , CA 05201 466 -67bL <br /> LILT 40 10/ 86 <br />