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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 cleanup 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. 'T, 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: C('2-2-(Yj <br />Operator's name: ck)ck M) Phone Number: 209 99 3-129 U <br />Facility name: },( C(', iff rftl fi Facility Address: -761 E . C�)c&bG LO <br />Hazardous substance found in the secondary containment:N()R& JJ <br />Quantity* A Concentration: X <br />Description of the actions taken to control and clean up the release* <br />U <br />The method and location of disposal of the released hazardous substance: <br />_TAk A 5jto ()icn <br />Description of actions t ken to repair the UST and to prevent future releases. Attach a copy of the <br />maintenance receipt:] %0 gaRej to }\ej 5h b(SQ�c, <br />Describe how the monitoring system was reactivated after repairs or replacement: <br />ed -6 Mf -)'C P&'Ca,M kF, I43 WCOU16D QN THEC_Xj`)-7-1NQ T2 <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 />