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�nglyzJiPj <br /> INVENTORY RECONCILIATION APR .11 198 <br /> QUARTERLY SUMMARY REPORT FORM <br /> r-14VIRorarr�rvr�,��� .�r� <br /> Facility Name: SHAUGHNESSY CAR WASH Tank f �60 <br /> uct <br /> 1 0 Re r�].ar <br /> Facility Address: 601 E. Miner Avenue 2 12 0100 ISuner Ural <br /> -Stockton. CA 95202 3 12 , 000 Req. Un] <br /> Telephone : ( 209) 465--2542 <br /> Person Filing, <br /> Report Lila Dillheimer <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 /> aInventory variations exceeded the allowable limits for this quarter. Y <br /> hereby certify under penalty of perjury that the source for the variation <br /> win not due to an unauthorized (leak) release. (Yes in Column 0 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank f, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f ,Amount <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 duct to <br /> a leak the incident shall be reported to S „J I, }{ 0 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 each <br /> quarter. <br /> (hurter I - January -Q Harch <br /> (,darter 2 - Apri l -0 Jude! <br /> Quarter 3 -- July --) September <br /> Quarter 4 - October --> Ikkcemher <br /> Send to: SAN JOAQULN LOCAL HEALTH DISTPICT <br /> 1601 K . Hazo C t coil , P . O . Box 2009 <br /> Kockcon , CA 95201 466 -67bl <br /> aT 40 10/ 86 <br />