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4 State of California UST Requirements APP °'X <br /> ENVik( ,N _ JH <br /> PERMIT/SERVICES <br /> r�t�rY�} 1 TANK GAUGING AND INVENTORY RECONCILIATION ANNUAL SUMMARY REPORT <br /> Facility No. (0=( Facility Operator ,/INS— Ltpu _Year <br /> Facility Address '4)q—/ W&cA 14m <br /> srKn <br /> Check 1✓)which method report is for. <br /> ® Inventory Reconciliation(Motor Vehicle Fuel) ❑ Manual Tank Gauging(Used Oil Tanks) <br /> Check(✓)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(✓)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 Repori(s)did not meet the requirements under the state law as noted below. <br /> AND,IF APPROPRIATE <br /> ❑ <br /> I herebycertify underpenalty of perjury thatthe source forthe 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 /> m41Uti Tank No. Amount of Variation <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> 6. <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 incidentshall be reported to the <br /> local undergroundstorage tank agency within twenty-four(24)hours. An unauthorized Release Reportshall be submitted within five <br /> (5)days. <br /> For stations utilizing Invento Re onciliation or Manual T Gauging,this report must be submitted to the local Underground <br /> Storage Tank Regulation A ncy n an annual basis, <br /> I <br /> Facility Operatorlsignatu 1 Ostp <br /> I <br /> Chevron USA.Products Company Sul1 j Retail Facility Compliance Guide <br />