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TANK GAUGING ANVENTORY RECONCILIATION ANL SUMMARY REPORT <br />Facility No. CHEVRON # Facility Operator: Year: <br />Facility Address: <br />Check (-4) which method report is for: <br />Fz- <br />Inventory Reconciliation (Motor Vehicle Fuel) ❑ Manual Tank Gauging (Used Oil Tanks) <br />L;necK Iv1 the appropriate statement it 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 Keconcivation Report did not meet the requirements under the state law. <br />Month Tank No. Amount of Variation <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 (S) 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 />A <br />