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QUARTERL�T INVEN <br />TORY R OR �. <br />JA ^I IL 9 <br />Facility Name: Facility Address: 322­5�rEM <br />City: Ti2F)C;1 <br />County: <br />State: 0-14,- <br />[�] <br />I hereby certify under penalty of perjury that all product <br />level variations for the above mentioned facility were <br />within allowable limits for this quarter. <br />Inventory variations exceeded the allowable limits for <br />E�this quarter. I hereby certify under penalty of perjury <br />that the source for the variation was NOT due to an <br />unauthorized (leak) (leak) release. <br />List date. tank f 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 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 Janaury 15 <br />Send To (Local Agency): <br />KEEP COPIES OF THIS FOAM FOR YOUR OWN RECORDS <br />