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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: _ Horron'c (lac Mnrt M,731 :12 <br /> Product <br /> Facility Wddress: 13475 N. Jacktone Rd U/L Premium <br /> E. Lodi, CA 95240 U/L Regular <br /> Regular <br /> Telephone : (209) 368-7L6 <br /> Person Filing <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. (No in Column 13 of the Inventory Reconciliation Sheet) <br /> ® Inventory variations exceeded the allowable limits for thin quarter. I <br /> hereby certify under Penalty of perjury that the source for the variation <br /> was not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, taok f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> I_ SEE ATTACHED INVENTORY CONTRni. StaEETS <br /> 2. ASTERISKS DENOTE VARIATIONS EXCEEDING ALLOWABLE LIMITS. <br /> 3. <br /> 4. <br /> S. <br /> Additional daces/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 S .J .L.H . D. environmental Ncalth <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 /> Quarter 1 - January --) March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> Scpccmher <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160L E . HazelLUn , P .O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 <br />