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STATISTICAL INVENTORY RECONCILIATI(YN 'MAI <br /> ANNUAL INVENTORY RECONCILIATION <br /> SUMMARY REPORT 22 <br /> From fEff 199V To <br /> Facility Name: CIRCLE R STORE # �� SLa <br /> Facility Address: 16470 CAMBRIDGE <br /> LATHROP CA 95330 <br /> 73 <br /> Establishment#: Y <br /> a. — <br /> Tank Number size Product <br /> 1 10,000 UNLEADED REGULAR GASOLINE <br /> 2 10,000 UNLEADED PLUS GASOLINE <br /> 3 4,000 - - UNLEADED PREMIUM GASOLINE <br /> ❑ I hereby-certify under penalty of perjury that all inventory variations for the above mentioned facility were <br /> /within allowable limits. " <br /> fjd Inventory variationsexceeded the allowable limits for this quarter.I hereby certify underpenalty of perjury that <br /> the source for the variation was not due to an unauthorized release (leak). - <br /> Date Amount Explanation <br /> (Please attach additional information on a separate sheet.) . <br /> If the source of variation,which exceeded allowable limits,was due to a leak,the incident shall be reported to the <br /> Department of Environmental Health Services within twenty-four (24) hours. In <br /> emergencies notify Emergency Response at(800)33-TOXIC.An IncidentReport must be mailed to this department <br /> within five 5) working days after the incident.— this report is mailed from the Circle R <br /> Enviro ental Department. <br /> Please su this form to the above address with your annual permit renewal. c -- <br /> €or CIRCLER CORPORATION— 0 <br /> Tank Facility Owner/ rator - - Date <br /> 7 <br />