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