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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: Shaluqhnessy Car Wash Tank <br /> Size Product <br /> Facility Address: 601 E. Miner Avenue � 6 000 Regular <br /> 12 000 Super Unl <br /> Stockton, CA 95202 3 12,000 Re Unl <br /> Telephone : ( 2 09) 465-2542 <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 13of the Inventory Reconciliation Sheet) <br /> LlInventory 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 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 1. <br /> z. <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 /> 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 /> Quarter f - January --> Harch <br /> Q,.iarter 2 - April --> June <br /> Quarter 3 - July --> Septemller <br /> Quarter 4 - October --> Dc-cember DISTRICT Send to: ��vZ . <br /> SAN JOAQ(IIN LOCALLOCALHEALTHHEADISTRICTV <br /> 160L E. . ]:cera l c , r .() . 1i()x 2()()g JAN 14 fig? <br /> SLackton , (;/l 05101 1466-6781ll(;T' 140, LO/86 ENVIROMENTAL HEALTH <br /> F ERMIT/SERVICES <br />