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Facility Name and Address: <br />Date: <br />Check which method report is fnr_ Inventory Reconciliation (Motor Vehicle Fuel) <br />_ Manual Tank Gauging (Used Oil Tanks) <br />I hereby certify under penalty of perjury that all inventory variations each month, for the <br />above mentioned facility, were within allowable limits, for the year <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 due to an <br />unauthorized release. <br />List month, tank #, and amount of variation for each month that the variation exceeded the allowable limits. <br />I. <br />2. <br />.7. <br />4. <br />5. <br />•• •M1.11•i 1 1 =_# ii 1;1: •1 t J - i:-�: i 1.:T' i(.. .►.. 1: .• <br />Operator Si e• <br />If the source of the variation which exceeds the California allowable limits was due to a leak, the incident shall be <br />reported to the local underground stage tank agency within 24 hours. An unauthorized Release Report shall be <br />submitted within 5 days. <br />For stations utilizing inventory Reconciliation of Manual Tank Gauging this report must be submitted to the local <br />Underground Storage Tank Regulation Agency on an annual basis. <br />CHEVC E M <br />oz -os -92 <br />Chevron <br />