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0 0 <br /> INVENTORY RECONCILIATION <br /> r ��} <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facilit Name: <br /> 7 SHAUGHNESSY CAR WASH Tank f ' <br /> 4. roduct <br /> Facility Address: 601 E. Miner Avenue 1 6"0& ' Re �.�lar <br /> 2 12_ 000 Sts er Unl <br /> Sfic�rkt on CA 95202 3 12 000 Rea. Unl <br /> Telephone : ( 209 ) 465-2542 <br /> Person Filing <br /> Report Lila Billheirner <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_ (N0 in Column 130f 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 as unauthorized (leak) release. (Yes in Column 13 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 I 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 snd 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 . L , 11 . D . Environmental Health <br /> within 24 hours and an unauthorized release report submitted. <br /> n e quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - J.-luunry H.irch <br /> Q•larter 2 - April --? J'JN1(- <br /> &Quarter 3 --. Sul --} Sc �temhr.r <br /> 11�37- <br /> tcr 4 October - ) D,-CVmt)er <br /> Send to: SAN JOAQU IN I,0CA1, HEALTH I I STIUCT <br /> 1601 E— haze 1 t (m • P . U . 13+ax )()fy) <br /> (;T 40 10/136 SLockton • CA 95201 460-0781 <br />