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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name. SHAUGHNESSY CAR WASH Tank t Size Product <br /> 1 6 ,000 - Regular <br /> Facility Address: 6011 E. [liner Avenue 2 12 1 000 Super U01- <br /> Stockton, CA 95202 3 12 ,000 Rea, U01. <br /> Telephone : ( 209 ) 465-2542 <br /> Person Filing <br /> Report Lila Billheimer <br /> VI hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable limits Eor -4:/ U iiJ� <br /> quarter. (So in Column 13 of the Loveutory Reconciliation Sheeti; �� `� <br /> OCT 13 1969 <br /> Inventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for th UISERWOEF ioo <br /> vas not due to an unauthorized (leak) rcleise. (Yes in Colum 1� AL HEALTH <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank E Amount <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amouats shall be continued on a separate 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 reporter! to S .J . L . 1{ . D . Environmental Health <br /> 'within 24 hours and an unauthorized release report submitted. <br /> Ilia quarterly summary report shall be submitted within 15 days of the end of cacti <br /> quarter. <br /> Quarter I - January -- March <br /> Q,lartcr 2 - April --3 June. <br /> Quarter ) - July --> Septemhur <br /> Quarter 4 - October --> [h�crmhe:r <br /> Send to: SAN JOAQUIN LClCAt HEALTH DISTRICT <br /> 1601 K . Hato 1 [ "n , P .{) . Am 2009 <br /> Srockcon , CA 95201 466 -6781 <br /> �T 40 10/ 86 <br />