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v� <br /> INVENTORY RECONCILIATION APR 15 S'3 s7 <br /> QUARTERLY SUMMARY REPORT FORM ENVIRGMENTAL HEALTH <br /> ES <br /> Facility Name: E F Kludt R- Sons, Inc Tank t ize Product <br /> .:I_ C <br /> Facility Address: 1126 E Pine St <br /> Lodi, Ca 9524 <br /> Telephone : 361;-0634 or 466-8969 <br /> Person i n <br /> Report <br /> I . ere rtify under penalty of perjury that all inventory variations for <br /> he above mentioned facility were within the allowable limits for this <br /> quarter. (No in Column 13of the Inventory Reconciliation Sheet) <br /> E] Inventory 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 unauthorized (leak) release. (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 f Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which exceeded allowable limits was due to <br /> a leak the incident shall be reported to S ,J ,L.H.D . Environmental Health <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 --> Narch P ' ', \ <br /> Quarter 2 - April --> June t <br /> L" ;'S.A <br /> Quarter 3 - July --� September 4P <br /> I?4 - October --� December R 1 5 <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT a�`�a'N/v 1�8j <br /> 1601 E . Hazelton , P .O . Box 2009 AU ���/SHS ' ^' <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/ 86 <br />