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r/ 8xaiaiT 100-34 <br /> 02/21/89 <br /> INVENTORY RECONCILIATION <br /> j QUARTERLY SUMMARY REPORT =ORM <br /> BUSINESS NAME ^j( krs <br /> svA/ r7.2uC' <br /> � 0 ?50NE ozo�- P35-105 z <br /> STREET ADDRESS '////J �Z+cY 9S37C� <br /> 1 4 <br /> Tank I.D. F <br /> Volume 14 ov u <br /> Contents WAr4- <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 APRIL i94o and ending u <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 /> I 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 t, 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 or paper for 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 requiatory 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 /> t. <br /> Signature a:!4� Title Sutoee✓ad'e <br /> Print :tame %/10WIfs P. F kn/AtwAOPS Date 6 ?u/tom f4 <br />