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• SAN JOAQUIN COUNTY • _ <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave., Stockton, CA 95205-6232 "y.i <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.oro/ehd <br /> APR 19 2016 <br /> RECORDING REQUIREMENTS <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. 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: <br /> Operator's name: L :F�vK Phone Number:3�k Q '� <br /> Facility name: �L� �+��c Facility Address: \�6 ls, Ln�� <br /> Hazardous substance found in the secondary containment: kci ZQS e\I r <br /> Quantity: V!;„Zy LjTj cs"' Concentration: NO LxrK00.&W 7 a S� t s <br /> Description of the actions taken to control and 4 <br /> clean upthe release: <br /> s— <br /> The method and location of disposal of the released hazardous substance <br /> Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the <br /> maintenance receipt: L�}tAL t�iy5 dN.,�� =:I fl\K <br /> k 4-L� 'tIAlx 410IJO +c- C. . k <br /> Describe how the monitoring system was reactivated after repairs or replacement: <br /> L�A� 1`l4� L���6tti �i �.oucFi Ta � a— ti <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 />