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• INVENTORY RECONCILIATI1 <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: <br />Facility Address: MM VALLAn-S FXXO', <br />.r ry L U 51v <br />Telephone: UA 95204 <br />Person Filing <br />Report : i� YI �t �, A - it A t.L-A/L <br />Tanx # i Size i Product <br />c� <br />QI hereby certify under penalty of perjury that all inventory <br />variations for the above mentioned facility were within the <br />allowable limits for this quarter. (No in column 13 of the <br />Inventory Reconciliation Sheet.) <br />(� Inventory variations exceeded the allowable limits for this <br />quarter. I hereby certify under penalty of perjury that the <br />source for the variation was not due to authorized (leak) <br />release. (Yes in Column 13 of the Inventory Reconciliation <br />Sheet). <br />List date, tank J, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Date Tank Amount Reason <br />1. HA y f /N/?acc44/0A,(lp <br />- _ <br />'07-" C 4.4 r /iDiv� <br />3. <br />5. <br />4-3 7 <br />r 1416--Ce--k/t/I--i5'07 <br />Additional dates/amounts shall be continued on a separate <br />sheet of paper and attached. <br />If the source of the variation which exceeded allowable limits <br />was due to a leak, the incident shall be reported to Public <br />Health Services of San Joaquin County.Environmental Health <br />Division, within twenty-four (24) hours and an unauthorized <br />release report submitted. <br />The quarterly summary report shall be submitted within fifteen (15) days of <br />the end of each quarter. Circle appropriate quarter. <br />Quarter 1 - January ---------- >March 4. ,�- <br />Quarter 2 - April ------- >June <br />Quarter 3 - July ------------>September <br />Quarter 4 - October --------->December <br />Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />l�til-E �I}toA-Ave. ,.0. Box 2009,r <br />Stockton, CA 95-201 <br />EH 23 019 (10/89) (209) 468-3420 <br />