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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Jackpot Tank a< <br /> Size Produc <br /> Fseility�Address; +n-Ig rfiArnUa T n <br /> no <br /> Rem„i,• <br /> n <br /> —Lod; rA norn U L Re u1 <br /> G1 , G Prem U L <br /> Telephone : (100) ,5q sus 10 00 <br /> S 0 . <br /> Person Filing 1 <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. (Ho in Column 13 of the Inventory Reconciliation Sheet) <br /> Inventory variacioas exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury that the source <br /> wasfor the varix ciao <br /> a■ aoc due to as uoauchorizcd (leak) release. (YX7SX74 <br /> �X7C?1�AX�'YRC{7C7D7F]CX3LX zJCApX AX}E�71 (Based on daily measurement error only.) <br /> List date, tank /, and amount for all variations Chat exceeded the <br /> allowable limics- <br /> D_te Tank E Amount <br /> 1- SEE ATTACHED INVENTORY CONRTOi. SHEET <br /> Z- ASTT'T?TSFq DFATr1TF <br /> 3. T+ 1T <br /> 44R <br /> TTng rr <br /> Fvrn,`TC ALLOWABLE LIMITS. <br /> 4. <br /> S. <br /> Additional dates/amouats shall be continued on a separate ■heel of <br /> Paper and attached. <br /> If the source of the variation which. exeeeded allowable limits was due to <br /> a leak the incident shall be reported to S ,J .L. H . D. <br /> within 24 hours and an unauthorized release report submitted. <br /> onmenCaL Ilea t[h <br /> The quarterly summary report shall be submitted within <br /> quarter. IS days of the end of each <br /> Quarter I - January --) March <br /> Qiarcer 2 - April --) June <br /> Quarter 3 - July --> septemher <br /> Quarter 4 - October --) <br /> (k ccmbcr <br /> Scnd co: SAN JCAQUI:I LOCAL HEALI'li UIS'1'ii1C'1' <br /> 160L E . I:azc 1 l++n , P . 0 . Ros 200') <br /> UCT 40 LO/HG $Lockron , CA 95201 1,66 -678L <br />