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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: DELICATO VINEYARDS rank / Size. <br /> Product <br /> F0�eility+ u 1 10 00. Leaded Gas <br /> Addre : 12001 S0. HWY 99 2 X10,-000. Unlea e as <br /> MANTECA, CA 9533 3 10, Dies 7' <br /> Telephone : (209) 982-0679 **AND NO OTHERS** <br /> Person Filing <br /> Report Richard D. Larson <br /> QI 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 13of the Inventory Reconciliation 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 /> vas not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank 1 Amount <br /> 1. DEC 513?D <br /> 2. LiJViLP;d IC <br /> vLAT'Af_ HEALTh <br /> 3. PERfvll r/SERVICES <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 allowable limits was due to <br /> it 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 /> Quarter 1 - January --) March <br /> Quarter 2 - April --> June <br /> `$uarcer 1 - .luty --> Septemh.• /moi<'0 <br /> Q.artcr 4 - cto cr -- [)<ccmbcr <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HazelLon , P .O . Box 2009 <br /> Stockton , CA 95201 466-6761 <br /> T 40 10/86 <br />