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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY RFPORT FORM <br /> Facility Name: Jackpot Tank Size <br /> Product <br /> Facility<Address: _401 S. rie rule i ne 4 n u r <br /> . T.odi ra 05?41 - Al2 _ 4 0 P <br /> t_ rem U LL Re ular <br /> Telephone : �, l0 000 H <br /> np} zFg_SFs�. <br /> Person Filing <br /> Reporc 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 Ioveatory Reconciliation Sheet) <br /> MV <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 CO an unauthorized (leak) release. f:XxaXa <br /> :l•R.Y14R��k41,Ti{}�}X1q�X15S(iC <br /> Aa[Y1S43C74701t7C71x#F7G74RXbARlEF7( (Based on daily measurement error only.) <br /> List date, tank i, aad amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank I Amount <br /> 1. SEE ATTACHED INVENTORY CONRTni, ;HFET <br /> Z� :aSTr•TtTsxS DT'.NOTr' VARTATI=—c F\'r -ZDZ <br /> IG ALLOSdABLE LI,fITS. <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 <br /> within Z4 hours aad an unauthorized release report sDubmitcedonmcntal Ficalth <br /> The quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter 1 - January --) March <br /> Qlarcer j - <br /> ApriL --) June <br /> Quarter I - July --) Scptcmhcr <br /> Qurcer 4 - October --) December <br /> S<nd co: SAN JOAQUI:1 LOCAL HEAL1'1i UIS'I'IiIC'1' <br /> 160L E . IIa7.C1t011 , P . O . Itox 2009 <br /> UCT 40 I0/86 Stockton , CA 95201 1#66 -67b1 <br />