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TANK GAUGING AND IN"9NTORY RECONCILIATION ANNUAL "UMMARY REPORT <br /> Facility No. CHEVRON # "facility Operator: wear: <br /> Facility Address: <br /> Check (J) which method report is for: <br /> ® Inventory Reconciliation(Motor Vehicle Fuel) ❑ Manual Tank Gauging (Used Oil Tanks) <br /> Check (4) the appropriate statement if state requirements were met: <br /> ❑ I hereby certify under penalty of perjury that all of the inventory variations each month, for the above mentioned facility and <br /> year, were within the allowable state limit. <br /> OR, IF FACILITY IS ON SIR: <br /> ❑ I hereby certify under penalty of perjury that all of the Statistical Inventory Reconciliation Reports, for the above mentioned <br /> facility and year, meet the requirements under law. <br /> Check (J) the appropriate statement(s) if state requirements were not met: <br /> ❑ Inventory variation(s)exceeded the allowable state limit as noted below. <br /> OR, IF FACILITY IS ON SIR: <br /> ❑ Statistical Inventory Reconciliation Report(s)did not meet the requirements under state law as noted below. <br /> AND, IF APPROPRIATE: <br /> ❑ I hereby certify under penalty of perjury that the source for the variation(s),or Statistical Inventory Reconciliation Report(s) <br /> which did not meet the requirements under the state law, was not due to an unauthorized release. <br /> List month, tank number, and amount of variation for each month that the variation exceeded the allowable limit, or the <br /> Statistical Inventory Reconciliation Report did not meet the requirements under the state law. <br /> Month Tank No. Amount of Variation <br /> 7. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> 6. <br /> Additional months shall be continued on a separate sheet of paper and attached. <br /> 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 <br /> underground storage tank agency within twenty-four(24)hours.An unauthorized Release Report shall be submitted within five (5)days. <br /> For stations utilizing Inventory Reconciliation or Manual Tank Gauging, this report must be submitted to the local Underground Storage Tank <br /> Regulation Agency on an annual basis. <br /> Facility Operator(Signature) Date: <br />