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• r <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Teleph-on(n(209Y468-3420 Fax.,(209J 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. <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. Ci) 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: (),, pw, <br /> Operator's name: 311 (-4 r,rte,. (vie Phone Number: 7 O'2 - 3 7-G -o-s c t <br /> Facility name: a� [.� (�_ (_f LJJAAe Facility Address: <br /> Hazardous substance found in the secondary containment: <br /> Quantity: ca2 Aft" S Concentration: <br /> Description of the actions taken to control and clean up the release: <br /> w2S�Lp ��,,//�p�h- <br /> 4l A. 1-:n1G4 AN�I/L�F F.(LMC ".L jp- <br /> Pl«. V r <br /> The method and location of disposal of the released hazardous substance: <br /> 4-i �_..__�mcC). <br /> 1 4flH ry .I'�Wi1Jt1 Q17NMlLTY!lr •- <br /> I V <br /> Description of actions t ke to repair the PST and to prevent future rel ases. Attach co y of the <br /> M <br /> is ntenance receipt: 1� �/p q Jae( �, �{���t� o <br /> Describe how the monitoring system was reactivated after repair or replacement: <br /> e <br /> %Gc.. tA. .�I-4- -� Pw.rhun! A�/!t�"' i�i`u� ct.�•��� <br /> I d090YAA se,Jr <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 />