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INVENTORY RECONCILIATION ASR 1 3 1��� <br /> QUARTERLY SUMMARY REPORT FORM �:-NVI RON MENTAL HEALTH <br /> PERMIT/SERVICES <br /> Facility Name: SHAUGHNESSY CAR WASH Tank t size Product <br /> 1 6,000 •Re ul.ar <br /> Facility Address: 601 E. Miner Avenue 2 12 ,000 Su or UnI. <br /> Stockton CA 95202 3 12 ,000 Rect. Unl <br /> Telephone : ( 209) 465-2542 <br /> Person Filing <br /> Report Lila Billheimer <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 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 /> was not due to an unauthorized (leak) release. (Yes in Columm 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 Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> S. <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 duc: to <br /> a leak the incident shall be reported to S . J L . H . D . Environmental licalth <br /> within 24 hours aad an unauthorized release report submitted. <br /> The quarterly summary report shall be s+ibmitted within 15 days of the end of cacti <br /> quarter. <br /> QuxrC.c:r I - January Harch <br /> Q•lartcr Z - April -> JUCI(- <br /> Quarter 3 - July --> Sciicemhor <br /> Q+,artcr 4 - October -> 0ocvMhcr <br /> Send to: SAN JOAQU IN LOCAL HEALTH DISTRICT <br /> 1601 1-. . Ha e 1 t coil , P . O . lir�x 2009 <br /> "Lock Lon , CA 95201 1,60 -6781 <br /> ,9T 40 10/ 86 <br />