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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: Flame Liquors Inc <br />FacilityAddress: 1301 W. Kettieman Lane <br />1 . ` Lodi. , Cal -if. 95242, <br />Telephone: (209) 33�3 <br />Person Filing <br />Report Rate ..,GrAfgna <br />® I hereby certify under penalty of perjury that all inventory variatio®s for <br />the above mentioned facility were within the .allowable limits for this <br />quarter. (No in Column 13of the Inventory Reconciliation Sheet) <br />® <br />Inventory variations exceeded the allowable limits for tbis quarter. I <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to as unauthorized (leak) release. (Tao is Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date, took f, sod amount for all variations that exceeded the <br />allowable lis.its. <br />Date Tank f Amount <br />I. A2ril 1987 1 0 <br />2. Lk2ril 1987 2 0 <br />3. April 1987 3 0 <br />4. <br />5. <br />Additional dates/amouats sham continued on -a sepai°* 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 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 />Quarter 3 - July --> September <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Haze 1 l 111 , 'P.O. BOX 2009 <br />Stockton, CA 45201 -466-6761 <br />LICT 40 10/86 <br />ENVIROMENTAL HEALTH <br />RMT/SERVICES <br />