CERTIFICATE OF STOCK INVENTORY

As of

BUSINESS NAME
TAX IDENTIFICATION NUMBER
ADDRESS
OWNER
SUPPLIER
DATE/TIME OF STOCKING

TANK NO. / PRODUCT QUANTITY NO. Marked

GAS STATION (BRANCH) ADDRESS RDO UNDERGROUND TANK NO. CAPACITY DESCRIPTION LUME Unit of Measure (Yes/No)

Submitted by:

_______________(Name)_________________
(Title/Designation/Date)

I declared under penalty of perjury that the aforesaid informartion are true and correct.
Subscribed and sworn to before me this ____ of _______ affiant exhibiting to me his/her______________