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APPENDIX <br />tiAUt INUAIYUIIYVrN1UnT 11MUNUILIA11U11A1111UHLoUImvIAnr ncrLin i <br />,iT�ySEI�V <br />PER IC1`� � . <br />Facility No. %® 5 Facility Opferaatt�or � ESA t .° YN, Year <br />Facility Address %4�2 <br />Check 1✓) which method report is for: <br />Inventory Reconciliation (Motor Vehicle Fuel) ❑ Manual Tank Gauging (Used Oil Tanks) <br />Check 1✓► 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 <br />facility and 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 <br />mentioned facility and year, meet the requirements under the state law. <br />Check t✓) the appropriate statementls) 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 Repori(s) did not meet the requirements under the 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 <br />Report(s) 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 <br />the Statistical Inventory Reconciliation Report did not meet the requirements under the state law. <br />Month Tank No. <br />1. <br />2. <br />3. <br />4. <br />5. <br />6. <br />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 <br />local underground storage tank agency within twenty four (24) hours. An unauthorized Release Report shall be submitted within five <br />(5) days. <br />For stations utilizing Inventory Reconciliation or Manual Tank Gauging, this report must be submitted to the local Underground <br />Storage Tank Regulation Agency on an annual basis. <br />Facility Operator (Signature) <br />M t P Date �: t <br />Chevron U.S.A. Products Company SL:11 Retail Facility Compliance Guide <br />