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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> lsacilitr Name: SHAUGHNESSY CAR WASH 'Tank t <br /> Size Product <br /> Facility Address: 601 E. Miner Avenue 6 000 Regular <br /> 2 12 000 Su er Unl <br /> Stoekf-on. CA 95202 3 12 000 Re . Unl <br /> Telephone : ( 209) 465-2542 <br /> Person Filing <br /> Report Lila Billheimer <br /> VAI 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. (Ho in Column 13 of the Inventory Reconciliation Sheet) <br /> QInventory 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 I, and amount for all variations that exceeded the <br /> allowable limits_ <br /> Date Tank I Amount <br /> i. <br /> z. <br /> 3. <br /> 4_ <br /> s. <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 . L. H D Environmental llealth <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 --? Harch <br /> iartcr - April --> June <br /> Quarter 3 - July --) septemhcr PAYMENT <br /> Quarter 4 - October --> 1}ecrmtrer RECEIVED <br /> Send to: SAN JOAQUIN LOCAL liEAI.1.11 DISTRICT JUl_ 6 1987 <br /> 1601 1: . Laze i t ()n . P . o . 13()x 2()()g <br /> Stockton , CA 95201 466-6781 kNVIR©NMENTAL HEALTH <br /> tli;T 40 10786 PERMITfSERVICES <br />