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INVENTORY RECONCILIATION <br /> DATE<D z'� O $c1 QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: E F Kludt & Sons Inc. Tank # Size <br /> Product <br /> Facility Address: 1126 E. Pine Street 1 20 000 Unl Plus <br /> Lodi Ca 95240 2 20,000 Re lar <br /> Telephone: 209 68-063 or 466-3969 20 000 Diesel <br /> Person Fklt 9 2 000 Kerosene <br /> Report: A. 2 000 Solvent <br /> I hereby certify under penalty of perjury that -all inventory variations <br /> for the above <br /> ithin the allowale limis for <br /> TM this quarter. m(Nooiinecolumn ed 113yofethe re wInventory ReconciliationtSheet. ) <br /> Inventory variations exceeded the allowable limits for this quarter. I <br /> ❑ hereby certify 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 /> i 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-four <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 /> Quarter 2 - April------------>June <br /> Quarter <br /> 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 /> �k Wake a SPPY (Yellow) for Kludt files and attach Inventory Reconciliation records for <br /> all tanks.) <br />