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TANK GAUGING ARID INVENTORY RECONCILIATION ANNUAL SUM RY REP T <br />Family NO. .E Facility Operator: Year. <br />Facifity s: <br />Check M which nwOod mom in for: <br />® IttreIItpry Reconeiliaaton (Motor Vehicle Fuel) 13 Manumt Tank (Uaod oil rank,) <br />CIMk the mpmpriaws t if state Muirgmerft were met: <br />❑ 1 hereby ,miry under penalty ofpetJtuy that ail of tlhe inventary variations each month, for the above mantiorhed facelity and year, <br />were witttW the allowable sane limit. <br />OR. IF FACILITY 19 ON SIR: <br />® l hereby asttify under penally al' petjuy that ail of the Statistical tnr Reconciliation Reports, for the above mentioned <br />facility and year. nkerthe requirements under law. <br />Q inventory variations) exceeded the ationble am limit as now below. <br />OP. IF FACILITY IS ON SIR: <br />❑ Statistical leve nWq ReconWiation Ropoms) did not mw ate rquiranents undrr gate law 83 reeled below. <br />AND, IF APPRO TS: <br />❑ 1 heteby,settify under chatty of geuuty that the source tar the varier• S), of Statistical Inventory Reconciliation Repott(x) <br />which did not mcci the requirements under the $we law, was not due to ate t mautamriax d netted,. <br />.Iat Month. tank rim , and Mount of vaHation for submoret the variation ex the allowable IlMit. or the <br />atonal atonths shalt be eaNtinued on a separate sheat of paper and atwhea. <br />Utter Maxy, of the vaarwilon wherh ettredr ( olifawraia allm.ablo i'irrrits uav dw to a leak, the inciden1,T4atl he reported to rhe local <br />rgroww stomege teak agency v uiein twentt fartr 1241 houm An utr«iathori.ed Refecase Reltnrt.,half br mebmitted within five (3) ddvs. <br />ialiona wii%inle Inventory keco"i iation w bfanudf 1 axk 60uging, this PePort roust be submiHed to the local lindergmvnd Storage f'ank <br />lotion n& <br />.4gnx^V oM an dnal bads. <br />ri realty Operator fslgatature) Delo: <br />