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eMIBIT 100-31 <br /> 02/21/89 <br /> ,IL <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT ?ORM <br /> BUSINESS NAME ^hli/KrssO.✓ /7,r'„ C 00, PHONE 835= Y,052- <br /> STREET <br /> aSLSTREET ADDRESS 9//0 WA ,' iRAcY r « 9637(c <br /> 1 2 3 4 5 <br /> Tank I.D. i <br /> Volume Dnaa <br /> Contents <br /> Y <br /> I hereby certify under penalty of perjury that all inventory variations <br /> for the above mentioned business were within allowable limits for the <br /> quarter beginning ikLy 2- /y90 and ending SFPT d9 I94'0 <br /> (NO in Column 13 of the Inventory Reconciliation Sheet.) <br /> Inventory variations exceeded the allowable limits for the quarter <br /> beginning and ending <br /> 1 hereby certify under penalty of perjury that the source for the <br /> variation was not due to an unauthorized (leak) release. (YES in <br /> Column 13 of the Inventory Reconciliation Sheet.) <br /> List date, Tank f, and amount for all variations that exceeded the <br /> allowable limits: <br /> Date Tank I Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. _ <br /> 5. <br /> (Continue on a separate sheet of gaper [or additional <br /> dates/amounts) <br /> If the source of the variation which exceeded allowable limits was due to a <br /> leak, the incident shall be reported to Department of Public Health and any <br /> required regulatory agency. An Underground Storage Tank Unauthorized Release <br /> (leak) /Contamination Site Report shall be submitted to the Department of Public <br /> Health and any required regulatory agency within 5 days. This report will be <br /> documented and sent by corporate office. <br /> The Quarterly Summary Report shall be submitted within 15 days of the end of <br /> each quarter. <br /> Quarter 1 - January - March <br /> Quarter 2 - April - June <br /> Quarter 3 - July - September <br /> Quarter 4 - October - December <br /> Signature Title ­IX—)WS. SuPE/&NS&I <br /> Print Name %an4if=E Date -29 s6mr 1710 <br />