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QUARTERLY INVENTORY REPORTING <br /> Facility Name: Ince. c � {fir �_ <br /> C t Tank Size Product <br /> Fac i 1 ity Address: S ? <br /> City: <br /> County: <br /> State: <br /> Waste 011 <br /> I hereby certify under penalty of perjury that all product <br /> F] level variations for the above mentioned facility were f <br /> within allowable limits for this quarter, <br /> Inventory variations exceeded the allowable limits forE,r <br /> APR ., .[.� <br /> nthinuarter. I hereby certify under penalty of perjury <br /> V �1 q <br /> that the source for the variation was NOT due to an �R �EIVT4L <br /> unauthorized (leak) release. /f��,� �H ?j ��� <br /> / <br /> '#.� d� �7' �5 f v <br /> List date. an an amount or all variations <br /> that exceed the allowable limits <br /> Date Tank Amount Date Tank f Amount <br /> _,. <br /> " <br /> The quarterly summary report shall be submitted within 15 days <br /> of the end of each quarter. <br /> Quarter i - January thru March — Submit by April 0 <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 FORM FOR YOUR OWN RECORDS <br /> DATE MAILED <br />