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INVENTORY RECONCILIATI( <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Horton's Gas Mart Tank # Size Product <br /> 449 6000 ITTIT Prpm <br /> Facility Address: 13475 N. Jacktone Rd. 715 10000 Unleaded <br /> E. Lodi, CA 95240 731 12000 IRegular <br /> Telephone: (209) 368-7465 <br /> Person Filing <br /> Report: Joseph G. 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. (No in Column 13 of the Inventory Reconcilation Sheet) <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 to an unauthorized (leak) release. <br /> t ' E (Based on daily measurement error only) <br /> List date, tank size and product stored, and amount for all <br /> variations that exceeded the allowable limits. <br /> Date Tank # Amount <br /> 1 . SEE ATTACHED INVENTORY CONTROL SHEETS <br /> 2. ASTERISKS DENOTE VARIATIONS EXCEEDING ALLOWABLE LIMITS. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet <br /> of paper and attached. <br /> If the source of the variation which exceeded allowable limits was due to a leak, <br /> the incident shall be reported to S.J.L.H.D. Environmental Health within <br /> 24 Hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted with 15 days of the end of each <br /> quarter. <br /> Quarter 1 - January --> March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --> December <br /> SEND TO: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton, P .O. Box 2009 <br /> Stockton, CA 95201 466-6781 <br />