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QUARTERLY INVENTORY PRTIN <br />Facility Name: <br />Tank Size Product <br />1, 6 <br />Facility Address:, <br />City: , 7 <br />` <br />.. ...kE;.> e <br />county: <br />State: � �'�` - <br />Haste Oil <br />I hereby certify under penalty of perjury that all product <br />Lilevel variations for the above mentioned facility were <br />within allowable limits for this quarter. <br />ventory variations exceeded the allowable limits foot; <br />this quarter. I hereby certify under 'penalty of perj <br />that the source for the variation was NOT due to an APR 3 1'", <br />unauthorized (leak) release • <br />List date. tank # and amount for all variations <br />that exceed the allowable limits <br />Date Tank Amount Date Tank Amount <br />The quarterly summary report shall be submitted within 15 days <br />of the and of each quarter. <br />Quarter 1 — January thru MarchSubmit by April 15 <br />Quarter 2 — April thru June it by July <br />Quarter 3 — July thru SeptemberSubmit by October <br />Quarter 4 — October thru December- Submit -by Janaury 15 <br />Send To cal Agency): <br />KEEP COPIES OF THIS FORM FOR YOUR OWN RECORDS <br />DATE MAILED c <br />