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INVENTORY RECONCILIATIOP. <br /> DATE:o O QUARTERLY SUMMARY REPORT FORM <br /> Facility Nam E F Kludt & Sons Inc. Tank <br /> # Size Product <br /> Facility Address : 1126 E. Pine Street 1 =000Kerosene <br /> us <br /> Lodi Ca 952 0 2 r <br /> Telephone: 209 68-06 or 6 -89 9 <br /> Person F' ' na eReport: t <br /> I hereby certify under penalty of perjury that .all inventory variations <br /> for the above mentioned facility were within the allowable limits for <br /> this quarter. (No in Column 13 of the Inventory Reconciliation Sheet. ) <br /> Inventory variations exceeded the allowable <br /> hereby certify limits for this quarter. I <br /> ❑ under penalty of perjury that the source for the varia- <br /> tion was not due to unauthorized ( leak) release. (Yes in Column 13 of <br /> the Inventory Reconciliation Sheet) . <br /> List date, tank # , and amount for all variations that exceeded <br /> the allowable limits . <br /> Date Tank # Amount <br /> 1 . <br /> 2. <br /> 3. <br /> 4 . <br /> 5 . <br /> Additional dates/amounts shall be continued on a separate sheet <br /> paper and attached. <br /> If the source of the variation which exceeded allowable limits was <br /> due to a leak, the incident shall be reported to San Joaquin Local <br /> Health District; Environmental Health Division, within twenty-fogr <br /> ( 24 ) hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within fifteen (15 ) days <br /> of the end of each quarter. <br /> Quarter 1 - January---------->March <br /> uarter 2 - April------------>June <br /> Quarter 3 - July------------->September <br /> Quarter 4 - October---------->December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton, P.O. Box 2009 <br /> Stockton, CA 95201 468-3420 <br /> EH 23 019 10/86 <br /> (ltake a copy (Yellow) for Kludt files and attach Inven.tory Reconciliation records for <br /> ` all tanks. ) <br />