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TANK GAUGING AND <br />F <br />ty No. CHEVRON # <br />ty Address:_ <br />INTORY RECONCILIATION ANNUA UMMARY REPORT <br />Facility Operator: Year: <br />Check (J) which method report is for: <br />® Inventory Reconciliation (Motor Vehicle Fuel) ❑ Manual Tank Gauging (Used Oil Tanks) <br />Check (q) 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 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 (,1) 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), of 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 Reconciliation <br />Month <br />1. <br />2. <br />3. <br />4. <br />5. <br />6. <br />did not meet the requirements unaer the state iaw. <br />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 (5) days. <br />For stations utilizing Inventory Recohciliation'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 />