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� r • <br />1 ItMotote • M1 - • <br />Facility Name and Address: Dates l 9 q 3 <br />LA <br />L� Q e C,A `352-1a <br />Check which method Wort is for. ✓ Inventory Reconciliation (MotorVehicle Fuel) <br />Manual Tank Gauging (Used Oil Tanks) <br />✓ I 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 ) 9 0�-Z— <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 <br />Tank # <br />Additional months, <br />► • :shall <br />:be <br />. <br />If the source of the variation which exceeds the California allowable limits was due to a leak, the <br />incident shall be reported to the local underground storage tank agency within 24 hours. An <br />unauthorized Release Report shall be submitted within 5 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 />RECEIVED <br />01992-1 (7-23.92) HEALTH <br />v' PERMIT/SERVICES <br />