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• 4 <br /> INVENTORY RECONCILIATION ��I�� � 4 101 <br /> QUARTERLY SUMMARY REPORT FORM <br /> ENVIROM1±"'TAL HEALTH <br /> F F-R!%�l!/SERVICES <br /> Facility Name: SHAUGHNESSY CAR WASH Tank t Size Product <br /> 1 6, 000 Reau1.ar <br /> Facility Address: 601 E. Miner Avenue 2 12 . 000___ Super Unl. <br /> Stockton, CA 95202 3 -- -121000 Req, Unl. <br /> Telephone : ( 209) 465--2542 <br /> Person Filing <br /> Report Lila Billheimer <br /> TAkI 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 /> © Ioventory variations exceeded the allowable 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 Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date* tank /, 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 exceeded allowable limits was due to <br /> a leak the incident shall be reported to S J 1, i1 . D . Environmental lfcalth <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 each <br /> quarter. <br /> Quarter I - January --) N.irch <br /> garter - Apr IL --) June <br /> Quarter 3 - July --> September <br /> Quarter 4 -- October --} I?ecvmher <br /> Send to: SAN JOAQUIN LOCAI, ]JEA1,11i DISTRICT <br /> 1.601 E , P . O . ho x 2009 <br /> Stockton , CA 951.01 466 -6761 <br /> t;T 40 10/ 86 <br />