COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

TANK GAUGING AND INVENTORY RECOF tATTON ANNUAL SUMMARY REPORT FecArI y y4 e6e) _ 7_ / % _/,� Fecilf y Operator I�v� l (� wy Year ` ( ) / Facility AddresJs o / �'v'7/t e%%'in/JN - z oC�l. wl Check (✓) which method report is for. ZInventoty Reconciliation (Motor Vehicle Fuel) ❑ Manual Tank Gauging (Used Oil Tanks) —� Che0 ,4,1) the appropriate statement if state requirements were met: I hereby certify under penalty of perjury that all of the Inventory variations each month, for the above mentioned facility and year, were within the allowable state limit. OR, IF FACILITY IS ON SIR: ❑ I hereby certify underpraalty ofpzrjury that all of the Statistical Inventory Reconciliation Reports, for the above mentioned faciirty and year, meet the requirements under the state law. Check: (✓) the appropriate statements) if state requirements were not met: ❑ Inventory variation(s) exceeded the allowable state limit as noted below. OR, IF FACILITY IS ON SIR: ❑ Statistical Inventory Reconciliation Report(s) did not meet the requirements under the state law as noted below. AND, IF APPROPRIATE: ❑ I hereby certify underpenalty of perjury that thesourcefor the variation(s), orStatistical Inventory Reconciliation Report(s) which did not meet the requirements under the state law, was not due to an unauthorized release. List month, tank number, and amount of variation for each month that the variation exceeded the allowable limit, or the Statistical Inventory Reconciliation Report did not meet the requirements under the state law. Mot look Ns} Amount of Variation 1. 2. 4. 5. 6. Additional months shalt be continued on a separate sheet of paper and attached. Note: If the source of the variation which exceeds tralirornia allowable limits was due to a leak, the incident shall be reported to the local underground storage tank agency within twenty-four (24) hours. An unauthorised Rekase Report shall be submitted within five (5) days. For stations utilizing Inventory Reconciliation or Manual Tank Gauging, this report must be submitted to the local Underground Storage Tank Regulation Agency on an annual basis. Facility Operator(Signawte) vi1�y" / �?'--v Date_112- ,oil 12 ,o11