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(QUARTERLY INVENTORY REP�TING <br />Facility Name: <br />Facility Address: <br />City: <br />County: <br />State: <br />mom— <br />�V <br />-7 <br />6 <br />5— <br />I.hereby certify under penalty of perjury that all product <br />Ellevel variations for the above mentioned facility were <br />within allowable limits for this quarter. <br />Inventory variations exceeded the allowable limits for r <br />, i <br />y <br />this quarter. I hereby certify under penalty of perjur C <br />Lff that the source for the variation was NOT due to an DEC 4 4.989 <br />unauthorized (leak) release. ENVIRONMENTAL HEALTH <br />PERMIT <br />List date. tank # and amount for all variations E R V iC- E 3 <br />that exceed the allowable limits <br />=1 <br />0 <br />0 <br />The quarterly summary report shall be submitted within iS 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 />KEEP COPIES OF THIS FORM FOR YOUR OWN RECORDS <br />