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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <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. OF <br /> AND <br /> 2. The release has not escaped the secondary containment. OF <br /> AND <br /> 3. The release does not increase the hazard of fire or explosion. TO F <br /> AND <br /> 4. The release does not cause deterioration of the secondary containment. 0 F <br /> If all conditions above are not fulfilled you must report the release to the San Joaquin County <br /> Environmental Health D11 epartment and other agencies as appropriate. Date of release: S 2 I t t <br /> Operator's name: L41e l _'a4 Lk-UelPhoneNumber: 7o�-ct31-�S(o <br /> / t <br /> Facility name: �5� `a�---� 3 Facility��A��ddress: <br /> Hazardous substance found in the secondary containment: <br /> Quantity: Concentration: <br /> De criptio of the actions taken to control and clean up the release: <br /> The method and location of disposal of the released hazard us substance: �g <br /> � � <br /> rte-- <br /> Description of actions taken to repair the UST and to prey�ant future releases. Attach a copy of the <br /> maintenance receipt: �� �� G .� / sem c�tv4 k.e�/t <br /> m <br /> Describe how the monitoring system 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 />