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1 <br /> QUARTERLY INVcNTORY HEPORTING <br /> Facility Name: 0,,Az& � Tank Size Product <br /> (,J�' e� z <br /> Facility Address: k 3 � � S°_ D <br /> City: <br /> County: S <br /> State: L� <br /> waste oil <br /> I hereby certify under penalty of perjury that all product <br /> Qlevel variations for the above mentioned facility were =" `"`✓ <br /> within allowable limits for this quarter. 5 � <br /> JAN <br /> Inventory variations exceeded the allowable limits for <br /> this quarter. I hereby certify under penalty of perjury <br /> that the source for the variation was NOT due to an <br /> unauthorized (leak) release. <br /> List date, tank t and amount for all variations <br /> that exceed the allowable limits <br /> Date Tank # Amount Date Tank # 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 0 <br /> Quarter 3 — July thru September Submit by October 15 <br /> Quarter 4 — October thru December — Submit by Janaury i5 <br /> Send To (Local Agency : S cl <br /> 0 <br /> KEEP COPIES OF THIS FORM FOR YOUR OWN RECORDS <br /> DATE MAILED / — `7 — ! U <br />