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TANK G <br />A <br />Facility Name and Address: <br />Date: <br />Check which method roort is -fQr: 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 />Mih Tank # <br />1. — <br />2. <br />3. <br />4. <br />Amount. of Variation <br />5. <br />6. <br />Additional months shall be continued on a separate sheet of paper and attached. <br />Operator Signature: <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 />CHEVCS" <br />02 -OS -92 <br />Chevron <br />NNW <br />