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_ • Vco <br /> JAN 2 7 1993 <br /> TANK GAUGING AND INVENTORY RECONCILIATION ENVIRONMENTAL HEALTH <br /> ANNUAL SUMMARY REPORT PERMn-/SERVIC <br /> Facility Name and Address: Date: I - �2 o - 7 3 <br /> C_tlaluY v� # a-o o ? b <br /> X747 v7es .� L� <br /> Check which method report is for. ✓ InventoryReconciliation(MotorVehicle Fuel) <br /> Manual Tank Gauging (Used Oil Tanks) <br /> JI hereby certify under penalty of perjury that all inventory variations each month, <br /> for the above mentioned facility, were within allowable limits, for the year <br /> Inventory variations exceeded the allowable limits for the year. <br /> I hereby certify under penalty of perjury that the source for the variation was not <br /> due to an unauthorized release. <br /> List month, tank #, and amount of variation for each month that the variation exceeded the <br /> allowable limits. <br /> Month Tank # Amount of Variation <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> 6. <br /> Additional months shall be continued o a se etWoattached. <br /> Operator Signature• <br /> If the source of the variation which exceeds tt Calif znia�able limits was due to a leak, the <br /> incident shall be reported to the local and ground storage tank agency within 24 hours. An <br /> unauthorized Release Report shall be submitted within S days. <br /> For stations utilizing Inventory Reconciliation or Manual Tank Gauging this report must be <br /> submitted to the local Underground Storage Tank Regulation Agency on an annual basis. <br /> 01992-1 (1-23-92) I <br />