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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Te7aphww (209)'468'=3420 Fax.,(209)468-3433 Web:www.siqov.orq/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. 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'sname:z C,. (-"1„�,(2 Phone Number: 70� 72C-n 9 <br /> Facility name: Fast (,j cc,g ,rw�Facility Address: <br /> Hazardous substance found in the secondary containment: <br /> Quantity: Concentration: <br /> SeWOJ Coct,1@0v s <br /> Description of the actions taken to control and clean up the release: <br /> T.-ueA c:,, -ed Crlw C7!i Tr ... og, s 04"( S✓u Y'r. <br /> The method and location of disposal of the released hazardous substance: Flc cenA t , <br /> Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the <br /> maintenance receipt: <br /> t v <br /> /lw o r Lsr r1,'Lv.G.L <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 />