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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: SHAUGHNESSY CAR WASH Tank t Size Product <br /> 1 <br /> 6,000 Re talar <br /> Facility Address: 601 E. miner Avenue 2 12 000 Suioer Unl <br /> St-orktan,_.CA 95202 3 1.2 000 Req. Unl_ <br /> Telephone : ( 209 ) 465--2542 <br /> Person Filing <br /> Report Lila Billbeirner <br /> XI 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 allovable 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 Colu=n 13 of the <br /> Inventory Reconciliation Sheet) ' <br /> List date, tank f, and amount for all variations chat exceeded the <br /> allowable limits_ <br /> Date Tank I Amount <br /> 1<. <br /> Z_ <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 r_xcueded allowable limits was due to <br /> a leak the incident shall be reported to S ,J L • 1i _ D _ Environmental liralth <br /> WLChin 24 hours and an unauthorized release report submitted. <br /> The quarterly summary rr_port shall be Submitted within 15 days of the end of cacti <br /> quarter. <br /> Quarter I - January Harch <br /> Qliarecr 2 - April --> Jua,e <br /> Quarter 3 - July --> Scptenhr.r <br /> Quarter 4 October --7 D-cvmtrer <br /> Send to: SAN .JOAQUIN LOCAL HEALTH UISTHICT <br /> 1601 I: . P , O . Iirrx 1()()r) <br /> " Lockton , CA 95201 400 -€ 781 <br /> ;T 40 10/ 86 <br />