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ANNUAL AUTOMATIC TANK GAUGING (ATG) SUMMARY REPORT <br /> (AII-inforrmation not clearly listed on attached monthly tapes must be entered) <br /> Annual summary reports are required for retail and non-retail facilities <br /> FACILITY NAME: PRODUCT: <br /> ADDRESS: TANK NO.: <br /> CITY: ZIP: CAPACITY: TANK OWNER/OPERATOR <br /> LAST TANK GAUGE CHECK': LAST LINE MONITORING EQUIPMENT CHECK': LAST METER <br /> CHECK': LAST PIPING TEST': ATG SYSTEM2: THRESHOLD': GPH <br /> ❑ All monthly ATG results were "pass" or appropriate corrective actions were taken. The local agency was notified <br /> within 24 hours of receiving a failure or an ATG leak rate above the leak threshold. <br /> ❑ All monthly inventory reconciliation results were within allowable variations or appropriate actions as described in <br /> Section 2646(e) were taken. The local agency was notified within 24 hours of receiving inventory reconciliation <br /> results above the allowable variation. <br /> Complete for All Twelve Months <br /> Summary of Test Results from Monthly ATG Reports <br /> Time Periods Pumping During: Test Levels Test Results Inventory <br /> Reconciliation <br /> Resultse <br /> Wait Test Wait Test Product Percent Leak Pass/ Actual° Pass/ <br /> Time Time Time Time Levels FuU Rate Faile Monthly Faii10 <br /> Variation <br /> Month Year (HRS)4 (HRS)s (Y/N) WN) (Inches) % (GPH) (Gallons) <br /> 1 � <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> 9 <br /> 10 <br /> 11 <br /> 12 <br /> Submit report within 15 days following the end of the last month of the twelve-month time period covered by this <br /> summary report. Send to: . (local implementing agency) <br /> I certify under penalty of perjury, that all information listed above is correct. <br /> Signature of Facility Tank Owner/Operator or Agent Date <br /> ' Enter date. Monitoring equipment and pressurized lines must be checked yearly. 'Enter name and model of ATG system. 3 Enter certified leak <br /> rate threshold. a Enter wait time between last delivery or input and start of tank test. "Enter the number of hours between the start and the end <br /> of the test. s Enter the inches of product in the tank (A minimum of 36 inches is required). 1 Enter the calculated leak rate as listed on.the test <br /> report. a Enter pass for leak rates less than the certified leak rate threshold. °Inventory reconciliation calculations must be done unless tank is 90% <br /> full or within 10% of last month's highest level. tO Enter pass if the actual variation is less than 130 gallons + I% of throughput. <br /> SWRCB•Juno 1,1996 <br />