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HXBIBIT 100-34 <br /> �.. / 02/21/89 <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> BUSINESS NAME 1)1eKE550A/ 72QG Ga , PHONE Zof-835-- y0s2- <br /> STREET ADDRESS g110 1V1)NSlQ/AFL wh j,r)cy qS-37C� <br /> 1 2 3 4 5 <br /> Tank I.D. f <br /> Volume <br /> Contents �le4eL <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 T4WL"R' /990 and ending 1nggc,-1 i490 <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 f, and amount for all variations that exceeded the <br /> allowable limits: <br /> Date Tank f Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5 <br /> (Continue on a separate sheet of 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 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 /> �i <br /> Signature � Title Stift z✓ S>/L <br /> %l�r�y ,1�-�=��-- <br /> Print Name ZLI� 'A-s F s Date Z A7zfL yn <br />