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QUARTERLY INVENTORY REPORTING <br /> Facility Name: 4J1KF0kT-C1fA-fZ7,F sHf-LL, Tank / Size Product <br /> ! �,Rro S u zcro'D <br /> Facility Address: /fts E. GH4-r-Ttx K%-'.l 2 ?,Sao K-6� <br /> City: - zTaC4,-zoAl 3 8,Q o kU zaav <br /> County: -;! AA V-4N <br /> State: �� <br /> Hastev�oll� <br /> F] I hereby certify under penalty of perjury that all prod <br /> level variations for the above mentioned facility were, <br /> within allowable limits for this quarter. <br /> Inventary variations exceeded the allowable limits forJUL " 01989 <br /> this quarter. I hereby certify under penalty of perjury <br /> that the source for the variation was NOT due to arL''!`Ai2ONMENTALHEALTH <br /> unauthorized (leak) release. <br /> PERMIT/SERVIC PF <br /> List date. tank t and amount for all variations <br /> that exceed the allowable limits <br /> Date Tank # Amount Date Tank t Amount <br /> The quarterly summary report shall be submitted within 15 days <br /> of the end of each quarter. <br /> Quarter 1 - January thru March — Submit by April 15 <br /> ✓Quarter 2 - April thru June Submit by July 15 <br /> Quarter 3 - July thru September — Submit by October 15 <br /> Quarter 4 - October thru December - Submit by Janaury 15 <br /> Send To (Local Agency) : <br /> KEEP COPIES OF THIS FORM FOR YOUR OWN RECOROS <br /> DATE MAILED <br />