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QUARTERLY INVENTORY REPORTING <br /> Facility Name: gqqa_Q� Tank +1 Size Product <br /> Facility Address: -171,Z W(A VLL <br /> City: lom <br /> County: <br /> State: C <br /> Haste Oil <br /> I hereby certify under penalty of perjury that all product .1-1 rft <br /> © level variations for the above mentioned facility were <br /> within allowable limits for this quarter. CEI <br /> Inventory variations exceeded the allowable limits for rr� 0�C r 2 3 <br /> ❑ this quarter. I hereby certify under penalty of perjury .,U,,A1EN T , <br /> that the source for the variation was NOT due to an err''` r�s�-'�` HE,%rM <br /> unauthorized (leak) release. <br /> List date, tank E and amount for all variations <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 and 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 Januury 15 <br /> Send To (Local Agency) : <br /> KEEP COPIES OF THIS FORM FOR YOUR OWN RECORDS <br /> DATE MAILED ' <br />