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TANK GAUGING AND INVENTORY RECONWA71ON ANNUAL SUMMARY REPORT FacliityNo, 1 Facf4tyOperator �1i ✓. "/C (��t�J __Year facility Address j0 lit/• (1 _ _e C_�/'1_An) 1,,4iJ e -- Check (✓) which method report is for. ❑ Inventory ReconciLatior (Motor Vehicle Fuel) Check (✓) the appropriate statement If state ret 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 underpenal(y of perjury that all of the Statistical Inventory Reconciliation Reports, for the above mentioned facility and year, meet the requirements under the state law. Manual Tank Gauging (Used Oil Tanks) Check (✓) the appropriate statement(s) if state reaulrements were not met ❑ Inventory variation(s) exceeded the al towable state limit as noted below. OIL 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 V I hereby certify underpenalty ofpedury that the sourcefotthe variation(s), orStatistical Inventory Reconciliation Report(s) which did not meet the requirements under the state law, was not due to an unauthorized release. Lis, 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. Tank lft 2. 3. 4. S. 6. Aaa,t!ona! months snap ae conttnueo on a separate shat of paper and attached. Note. If the source of the variation which exceeds California allowable limits was due to a leak, the incident shall be reported to the local underground storage tank agency within twenty-jour(24) hours. An unauthorized Release Report shall be submitted within five (5) days. For stations utilizing Inventory Reconciliation or Manual Tank Gauging, this report trust be submitted to the local Underground Storage Tank Regulation Agency on an annual basis. FsctittyOperate-'Signature) Date-----� V