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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Faciuty If=": D & D MINI MART <br />34223 N- W111044 as <br />Facilit 4ddress: Lodi, CA 05240 <br />Telephone: <br />Person ng <br />Report <br />J A N <br />I hereby certify under penalty of perjury that all inventory variations f <br />the above mentioned facility were within the allowable limits for this <br />quarter. (No in Column 13of the Inventory Reconciliation Sheet) i <br />AInventory 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) rele�ae. (Yes in Column13 of the <br />Inventory Reconciliation Sheet) <br />List date, tank f, and amount for all variations that exceeded the <br />allowable limics. <br />F—M-.1 "M <br />2. <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 at-lowable 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 />#;, I - January March <br />Quarter 2 - April June <br />Quarter 3 - July September <br />Quarter 4 - October Dt--ccmber <br />Send to: SAN JOAQUIN 1,0CA1, HEALTH DISTRICT <br />1601 E'. !Haze llon, P.O. Box 2009 <br />SLockton. CA 95201 466-6781 <br />:T 40 10/86 <br />