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• � �`TJ,�jp=l <br /> INVENTORY RECONCILIATION <br /> ii'7 1 ':: EPR7 <br /> QUARTERLY SUMMARY REPORT FORM <br /> ENVIROMEivTAL HEALTH <br /> Facility Naa,e: E. F. Kludt & Sons, Inc. Tank ixe Product <br /> 1 20,000 Unl Plus <br /> Facility Addrems: 1126 E. Pine Street 1 20,000 Regular <br /> _Lodi, California 95240 1 20 000 Diesel <br /> Telephone : (209) 368-0634 or Sktn. 466-8969 <br /> Person F�ing nI <br /> Report ��i��,�„�X <br /> Richard' A. u <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (No in Column 13of the Inventory Reconciliation Sheet) <br /> ElInventory variations exceeded the allowable limits for this quarter. i <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to an unnuthori:ed (leak) releise. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank /, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank / Amount <br /> i. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> parer and artached- <br /> If the source of the variation whichexceeded allowable Limits was due to <br /> a leak the incident shall be reported to S .,J , L.H . D . Environmental llcalth <br /> within 24 hours and an unauthorized release report submitted. <br /> The Quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) March <br /> Qaartcr 2 - April --> June <br /> Quarter 3 - July --) September <br /> Quarter 4 - October --) lkcember <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 60 L E. . 11aze l ton . P .O . Rox 2009 <br /> Stockton , CA 95201 466 -6781 <br /> (ICT 40 10/86 <br />