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QUARTERLY INVENTORY REPOR 4"1 <br />Facility Name: ,,--, <br />Facility Address:�� <br />City:Jr®©^�. <br />County: <br />State: - <br />ENVIRONMENTAL HEALTH <br />VICE'S <br />Tank <br />Size <br />Product <br />�2 <br />-16 <br />SLI t) <br />e <br />t3 . <br />C-2 <br />azaL <br />Haste Qil <br />I hereby certify under penalty of perjury that all product <br />F] <br />level variations for the above mentioned facility were <br />within allowable limits for this quarter. <br />eL- <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 <br />Tank # <br />Amount <br />�2 <br />-16 <br />t3 . <br />C-2 <br />azaL <br />�-/ <br />3 <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 d — October thru December — Submit by Janaury <br />Send To (Local Agency): <br />a <br />KEEP COPIES OF THIS FORM FOR YOUR OWN RECORDS <br />DATE MAILED y=�� <br />