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SRN JOAQUIN COUNTY <br /> • RECF-,�.-.:]VED <br /> ENVIRONMENTAL HEALTH DEPARTMENT MAR 3 0 2017 <br /> 1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.s'gov.org/ehd <br /> ENVIRONMENTAL HEALTH <br /> RECORDING REQUIREMENTS DEPARTMENT <br /> FOR UNAUTHORIZED RELEASES <br /> An owner or operator is required to record all releases from the primary containment, as approved in <br /> this facility's Response Plan. This form may be used to meet the recording requirements* if all of the <br /> conditions below are true. <br /> 1. The owner or operator can clean up the release from the primary containment <br /> within 8 hours after the release was detected or should have been detected. Cf F <br /> AND <br /> 2. The release has not escaped the secondary containment. F <br /> AND f� <br /> 3. The release does not increase the hazard of fire or explosion. F <br /> AND F <br /> 4. The release does not cause deterioration of the secondary containment. <br /> If all conditions above are not fulfilled you must report the release to the San Joaquin County <br /> Environmental Health Department and other agencies as appropriate. Date of release: /-�u!� �V <br /> Phone Number• 6 r93 �`f <br /> Operator's name: J hc���-S �� ��t' ✓� <br /> Facility name:A -10 �,3�-"- Facility Address: *rte `. ; '' 6 <br /> Hazardous substance found in the secondary containment: f <br /> �j Concentration: <br /> Quantity: Iy ft 4; <br /> Description of the actions taken to control and clean up the rete se: <br /> "t D rw M L <br /> The method and location of disposal of the released ha ardous substance: qLso- ��. 4- <br /> Description of actions takeno1 repair the UST and to prevent future releases. Attach a copy of the <br /> maintenance receipt:1G Ike Z-4 n rl Af�-7—V, bc�e c f©r� 0 1 Gel o t,L <br /> Desbe how the monitor sy�7stem was reactivated after repairs or replacement: <br /> Attach printout from continuous monitoring system, maintenance receipts, manifests, photos, etc. <br /> Retain this document with your monitoring records for review during the annual inspection by our department. <br /> *See the California Code of Regulations, Title 23, Section 2651 and California Health & Safety Code Section <br /> 25294 for further requirements. <br />