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i • <br /> SAN.f OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTRE(--,%,EivFc <br /> 1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd M" 3 0 2017 <br /> RECORDING REQUIREMENTS ENVIRONMENTAL HEALTH <br /> FOR UNAUTHORIZED RELEASES 11FP.ARTMENT <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. F <br /> AND <br /> 2. The release has not escaped the secondary containment. F <br /> AND <br /> 3. The release does not increase the hazard of fire or explosion. F <br /> AND <br /> 4. The release does not cause deterioration of the secondary containment. F <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: --% 14 <br /> Operator's name Phone Number:, <br /> Facility name: H .kS5 d S Facility Address: V900 Inec <br /> 11 <br /> Hazardous substance found in the secondary containment: 4- A <br /> Quantity: _.4) Concentration: A <br /> Description of the actions taken to control and clean up the release: <br /> _C' 4 i 4 ed in <br /> ,. 4 <br /> The method and location of disposal of the released hazardous substance: <br /> l' <br /> �. <br /> Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the <br /> maintenance receipt: rde:— nIS c-rte :4 -4 <br /> U)ek <br /> I`q 1p e,, L e- <br /> Describe how the monitoring system was reactivated after repairs or replacement: <br /> ., <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 />