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QUARTERLY INVE-NTORY REPORTING <br /> Facility Name: i t 0 Tank f Size Product <br /> Facility Address: Z-(3 / E <br /> City: <br /> County: <br /> State: <br /> Waste oil <br /> I hereby certify under penalty at perjury that all product <br /> level variations for the above Mentioned facility were <br /> within allowable limits for this quarters. ; +, <br /> Inventory variations exceeded the allowable limits for <br /> ❑ this quarter. I hereby certify under penalty of perjury <br /> MAY 4 10.0.0that the source for the variation was NOT due to an <br /> unauthorized (leak) release. `-WV1R0NMEN 1 AL HEAL 1 f <br /> List date, tank # and amount for all variations PERMIT/SERV;CES <br /> that exceed the allowable limits <br /> Date Tank # Amount Date Tank f Amount <br /> The quarterly summary report shall be submitted within 15 days <br /> of the end of each quarter. <br /> Quarter i — 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 /> V <br /> C\ <br /> KEEP COPIES OF THIS FORM FOR YOUR OWN RECORDS moo o� <br /> _ Z <br /> DATE MAILED _ <br />