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ANNUAL AUTOMATIC TANK GAUGING (ATG) SUMMARY REPORT <br /> WLinf ftmation 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:[d Gt o/[ /iLTdLL.c/ iJl�a�� • (29t�t ¢ 1 PRODUCT: U n/LErI•p <br /> ADDRESS:_25_,20 L-1gC Y 1S L TANK NO.: <br /> CITY: / peac-e ZIP:gY37(, CAPACITY: i000' TANK OWN ER/OPERATORC/rr ap /RncY <br /> LAST TAN GAUGE CHECK':� � LAST LINE MONITORING EQUIPMENT CHECK':8/BQ;LAST METER <br /> CHECK': 8 4 LAST PIPING EST : / ATG SYSTEM':✓rlr(a� TCS- SOTHREgHOLD3:O_2 G P H <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 LevelsI Test Results Inventory <br /> Reconciliation <br /> Results' <br /> Wait Test Wait Test Product Percent Leak Pass/ Actual' Pass/ <br /> Time Time Time Time Level' Full Rate Fail' Monthly Faille <br /> Variation <br /> Month Year IHRSI• IHRSI' (Y/N? (YIN) (inches) % IGPHI' (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 /> S;gn'dtLVe of FaciliVf Tank Owner/Operator or Agent Date <br /> ' -Enter data. Monitoring equipment and pressurized lines must be checked yearly. 'Enter name and model of ATG system. ' Enter certified leak <br /> rate threshold. ` Enter wait time between last delivery or input and start of tank test. 'Enter the number of hours between the start and the and <br /> of the test. a Enter the inches of product in the tank (A minimum of 36 inches is required). r Enter the calculated leak rate as listed on the test <br /> report, a Enter pass for leak rates less than the certified teak rate threshold. "Inventory reconciliation calculations must be done unless tank is 90% <br /> full or within 10% of last month's highest level. 1OEnter pass if the actual variation is less than 130 gallons + 1% of throughput. <br /> sWNcsJ.I, 1996 <br />