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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.sjoov.org/ehd <br /> RECORDING REQUIREMENTS <br /> FOR UNAUTHORIZED RELEASES <br /> owner or operator is required to record all releases from the primary containment, as approved in <br /> is facility's Response Plan_ This form may be used to meet the recording requirements' if all of the <br /> onditions below are true. <br /> 1. The owner or operator can dean up the release from the primary containment <br /> within 8 hours after the release was detected or should have been detected. T <br /> AND <br /> 2. The release has not escaped the secondary containment. T F <br /> AND ,,-� <br /> 3. The release does not increase the hazard of fire or explosion. T/F/ <br /> AND vv <br /> 4. The release does not cause deterioration of the secondary containment. T F <br /> f all conditions above are not fulfilled you must report the release to the San Joaquin County <br /> nvironmental Heal epartment Ji andhe1r agencies as appropriate. Date of release: •2 <br /> perator's name: , rcL% Phone Number: 7A2r4% - ri��--$ VAC <br /> adlity name: nr�2P/ 14+» I'�►`� Facility Address: \4��oC+Z t 156'8 <br /> p�azardous substance found in the secondary containment: Ylrrv�s _ <br /> uantity Qt�AIM� ation: ``y <br /> Descriptio f the actions taken to control and clean up the release: REG o �,/ ED <br /> MAR D 8 2015 <br /> ENVIFi01VMENTAL <br /> The method and location of disposal of the released hazardous substance:1t- <br /> Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the <br /> maintenance receipt= J�-_;1O[ 'atf.r i,. I- I�f-l4• � — <br /> iitzc� psi.v crn So %E ,.n.Y'.•Slyldd--- �c.aci <br /> 3 z • 1a el&4- naw t c0•. c«. <br /> Describe how the monitoring system was reactivated after repairs or replacement: <br /> C„ CVTY\CL " <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 /> Loo/ Zo0'd OHL# t69t$££60Z £Z OL 9L07/90/E0 <br />