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r <br /> . INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY RF_PORT FORM <br /> Facility Name: SHAUGHNESSY CAR WASH Tank Size <br /> 1'roduc t <br /> Facility Address: 601 E. Miner Avenue 2 16 0002,000 Super <br /> ular <br /> per Unl <br /> Stockton, CA 95202 3 12, 000 Re Unl <br /> Telephone : _( 209) 4 5-2942. <br /> Person Filing <br /> Report Lila Billheimer <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 13 of the Inventory Reconciliation Sheet) <br /> E] Inventory 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 Columnl3 of the <br /> Inventory Reconciliation Sheet) <br /> List date, taok #, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank E Amount <br /> 1. <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 whichexceeded allowable limits was due to <br /> a leak the incident shall be reported to S .J .L . H . D . 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 /> C �, 2 <br /> January --) March <br /> - April > June <br /> Quarter 3 - July --) September <br /> Qrjarter 4 - October --) December <br /> Send to: SAN JOAQU IN LOCAL HEALTH DISTRICT <br /> 1601 E . Haze a l on , 1) .O . !icer 2009 <br /> 11G1' 40 I0/$6 Stockton , CA 95201 466-67bi <br />