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SAN JOAQUIN COUNTY F <br /> 'ENVIRONMENTAL HEALTH DEPARTMENT <br /> Tri .� <br /> 1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.slgov.orq/ehd 3 0 2017 <br /> RECORDING REQUIREMENTS NV�RONM�NTAi_ HEALTH <br /> FOR UNAUTHORIZED RELEASE nPPAPTNIENT <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 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: '34,fvie 24)/ <br /> Operator's name-1111444 Phone Number: t; <br /> Facility name: /� 6n ce r i _ Facility Address: 1-1906 S <br /> Hazardous substance found in the secondary containment: � <br /> Quantity: Concentration: A LL 3 S - <br /> Description of the actions taken to control and clean up the release: <br /> The method and location of disposal of the released hazardous substance: a<,e- 66-Sb v b e-• — <br /> iz f e•r u l n�U , icJ <br /> Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the <br /> maintenance receipt:_t,.)6. Qa - h a-zP <br /> Describe how the monitoring system was reactivated after repairs or replacement: <br /> 7 <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 />