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INVENTORY RECONCILIATION JAN 8 TPP <br /> QUARTERLY SUMMARY REPORT FORM ENVIRONIVIENTALHEALTH <br /> PERMIT/SERVICES <br /> Facility Nsme: SHAUGHNE:SSY CAR WASH Wank t Size Product <br /> 1 6 000 •Re uJ.ar <br /> Facility Address: 601 E. Miner Avenue 2 12 ,000 Suioer Unl_ <br /> Stockt-on CA 95202 3 12 , 000- Rea. Unl_ <br /> Telephone : ( 209) 465-2542 <br /> Person Filing <br /> Report Lila Bi llbeinier <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 13 of 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 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 I Amount <br /> 1. <br /> 2_ <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 cxceeded 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 cacti <br /> quarter. <br /> QuarCer I - January March <br /> (darter 2 - April --> J,aii,- <br /> QRjarter ] - July _> Scrcemhor <br /> Quartcr 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTIZICT <br /> 160L 1•: . Eaze 1 t (4n , P . 0 . hox 2009 <br /> SLockuon , CA 95201 46() - x, 781 <br /> ,;I- t.0 10/86 <br />