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Jr k4 <br />• k <br />INVENTORY RECONCILIATION CEIVE <br />QUARTERLY SUMMARY REPORT FORM 0 CT 1 8 1n <br />.,ENVIRONMENTAL HEALTH` <br />Facility Name: Is ��<� _�cnniTank <br />Facility Address: ` In, C)�2o <br />M A; JT'1 <br />Telephone: <br />Person Fi n <br />port <br />.. <br />0 I hereby certify under penalty of perjury that all inventory variations for <br />the above mentioned facility were within the allowable limits for this <br />quarter. (No in Column 13of the Inventory Reconciliation Sheet) <br />Inventory variations exceeded the allowable'limits for this quarter. I <br />hereby certify-under penalty of perjury that the source for the variation <br />s not due to an unauthorized (leak) release. (Yes in Column 13 of the <br />inventory Reconciliation Sheet) <br />List date, tank #, and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank # Amount <br />2. - -- — <br />3. <br />4. �- " °7iK <br />C <br />