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QUARTERLY= INVENTORY REF IRT ING <br /> �( Tank / Size Product <br /> Facility Name: ��/2P��7-CH�1zr�R 8�9°a 5D 2otro <br /> Facility Address: 1313 E . CH-4nrEk Yti Y <br /> z l0,a� l?EG v[.kyc <br /> { �o orro Au ammo <br /> City: sT°0Kroiv <br /> County: �! so'44urry <br /> State: e41-1r- <br /> Haste 01, <br /> I hereby certify under penalty of perjury that all product <br /> ❑ level variations for the above mentioned facility were <br /> within allowable limits for this quarter. <br /> inventory varlatl3ns exceeded the allowable limits for <br /> this quarter. I hereby certify under penalty oEl f perjury <br /> that the source for the variation was NOT due to an <br /> unauthorized (leak) release. <br /> List date. tank f and amount for all variations <br /> that exceed the allowable limits <br /> C <br /> Oats Tank # Amount Date Tank 0 Amount <br /> 7T 'PA4 <br /> The quarterly summary report shall be submitted within 15 days <br /> of the and 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 1 - October thru December - Submit by Janeury 15 <br /> Send To (Local Agency) : <br /> KEEP COPIES OF THIS FORM FOR YOUR OWN RECORDS <br />