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_ � PORTING <br /> GU ARTEREY IN <br /> V �-cNTORY RE <br /> Tank f Sizrwasteoll <br /> Facility Name. bFacility Address: ----- pcity: <br /> County:State: <br /> I hereby certify under Penalty of Perjury that all product <br /> ❑ <br /> for the above mentioned facility were <br /> level variations y N <br /> for this quarter. <br /> within allowable limits ceeded the allowable limits for ,JAN 2 3 1950 <br /> Inventory variations ex <br /> this quarter. I hereby certify under Penalty of P� �IRONMENT.AL HEAL; <br /> that the source for the variation was NOT due to an <br /> PrRi: <br /> unauthorized (leak) release. <br /> List date. tank E and amount for all variations <br /> that exceed the allowable limits <br /> Date Tank 0 Amount <br /> Oats Tank t Amount !� <br /> )O.A ( � � -.lam <br /> 1030 u JL <br /> 3 <br /> The quarterly summary report shall be submitted within 15 days <br /> of the end of each quarter. March _ Submit by April 15 <br /> Quarter i - January thru _ Submit by July 15 <br /> Quarter 2 - April thru June <br /> Quarter 3 - July thru September — Submit by October 15 <br /> Quarter A - October thru December - Submit by Janeury 15 <br /> Send To (Local Agency) : <br /> KEEP COPIES OF THIS FORM FOR YOUR OWN RECOROS <br /> DATE MAILED <br />