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Inventory Reeonciliatinn: •tejl)i Summary Report Form DATE; L Product Facili me: E F Kludt & Soni Inc, 1 20,000 Unl Plus _ 0 000 Re lar Facility Address : 1126 E. Pine Str,:at 20 0 0 Diesel Lodi Ca 952 0 2 000 Kerosona Telephone: 209 368-0 3 or !. ;>-39 9 2 000 Solvent Person Filing Report: I hereby certify under penalty of perjury that all inventory variations for the above mentioned facility were within the allowable limits for this quarter . (No in Column 13 of the Inventory Reconciliation Sheet, ) ❑ Inventory variations exceeded the allowable limits for this quarter. 1 hereby certify under penalty of perjury that the source for the varia- tion was not due to unauthorized ( leak) release. (yes in Column 13 of the Inventory Reconciliation Sheet ) . List date, tank Y , and amount for gall variations that exceeded the allowable limits . Date Tank K Amount 1 . 2 . 3 . 4 . 5. Additiondates/amounts shall be continued on a separate sheet paper and attached. If the source of the variation which exceeded allowable limits was due to a leak , the incident shall be reported to San Joaquin Local Health District; Environmental Health Division, within twenty-four ( 24 ) hours and an unauthorized release report submitted. The quarterly summary report shall be submitted within fifteen ( 15 ) days of the end of each quarter. Quarter 1 - January---------->March 11: uarter - April------------>June Quarter 3 - July------------- >September Quarter 4 - October---------->December Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. Hazelton, P.O. Box 2009 Stockton, CA 95201 468-3420 Ell 23 019 10/86 -SIG_ (Make._a_coPY (Yellow for l..tudt fi7.e:: and ettu tanks. ) ---- ch lnvento co Rcnci].i.etiou records for all ---