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ft <br />uNOcnLQ • • <br />W •` <br />8:4001 <br />S/S #. BUSINESS NAME: <br />Address: <br />I Quarter # <br />Start Date: <br />End pate: <br />Fill out this form quarterly <br />and send in with all other <br />forms, as applicable. <br />KEEP COPIES OF ALL FORMS <br />YOU MAIL OUT. <br />Tank # Capacity (gal) Product <br />CHECK ONE BOX BELOW AS APPLICABLE: <br />7] U l hereby certify under the penalty of perjury that all product level variations for <br />;his facility were within allowable limits for this quarter. ("NO" in cloumn 12, <br />Inventory Reconciliation Sheet; "NO" in column 7, Tank Gauging Sheet; "OK" in all <br />applicable columns of the Daily Visual Monitoring Log). <br />'j inventory variation at this facility exceeded the allowable limits for this quarter. <br />UU 1 hereby certify under penalty of perjury that the source for the variation(s) was <br />not due to an unauthorized (leak) release. ("YES" to any of the above). <br />There was an unauthorized (leak) release at this facility during this quarter. <br />I' <br />hereby certify under penalty of perjury-- that all necessary corrective actions <br />have been or are being taken. <br />DEALER'S SIGNATURE/DATE: <br />LIST DATE, TANK # AND AMOUNT FOR ALL VARIATIONS THAT EXCEEDED THE ALLOWABLE <br />LIMITS: <br />DATE TANK # AMOUNT <br />THIS QUARTERLY REPORT SHALL BE SUBMITTED TO = THE REGULATING LOCAL AGENCY WITHIN <br />15 DAYS OF THE END OF EACH QUARTER: <br />QUARTER <br />JANUARY—MARCHQUA- <br />- <br />2 <br />APRIL—JUNEQUARTER <br />3 <br />JULY— SEPTEMBER <br />Submit <br />by <br />October 15 <br />QUARTER <br />fOCTOBER—DECEMBER <br />4 <br />...-. ..`+ <br />Submit <br />by <br />January 15 <br />