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Chevron <br />Chevron U.S.A. Inc. <br />1 <br />� I <br />MONTHLY REPORT <br />S/S #: BUSINESS NAME: <br />Address: <br />Monthly #:_ <br />Start Date: <br />End Date: <br />Yeor. <br />Fill out this form monthly <br />and send in with all other <br />forms, as applicable. <br />KEEP COPIES OF ALL FORMS <br />YOU MAIL OUT. <br />Tank # Capacity (gal) Product <br />I <br />I i <br />• � i <br />I <br />CHECK ONE BOX BELOW AS APPLICABLE: <br />I hereby certify under the peneity of perjury that all product leve' variations f07 <br />this focility were within allowable limits for this quarter, l"NO" it cciumn <br />Product Monitoring Form; "N0" Oil Tonk Monitoring Sheet; "OK" it c. i <br />applicable columns of the Doiiv Visuol Monitoring Loc), <br />rove^tory variation of this facility exceeded the oliowable limits for :lis auc`:er. <br />1 here'ty certify under penalty of purjury trot the source for the vorie ions was <br />I not due to on unauthorized (leak) release. ("YES" to any of the above) j <br />17 There was en unouthor12ed (leak) release at this facility during this month. <br />1 hereby certify under penalty of purjury that all necessary corrective octions <br />hove been or ore being taken. <br />DEALER'S SIGNATURE/DATE: - <br />LIST DATE, TANK #r AND AMOUNT FOR ALL VARIATIONS THAT EXCEEDED THE <br />ALLOWABLE LIMITS: <br />DATE TANK # AMOUNT 1 <br />THIS MONTHLY REPORT SHALL BE SUBMITTED TO THE REGULATING <br />LOCAL AGENCY WITHIN 15 DAYS OF THE END OF EACH YEAR. <br />CHEVA 8/28 <br />