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4 <br />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.s4gov.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 />OT F <br />AND <br />2. The release has not escaped the secondary containment. <br />F <br />AND <br />3. The release does not increase the hazard of fire or explosion. <br />✓�T F <br />AND <br />4. The release does not cause deterioration of the secondary containment. <br />`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: <br />Operator's name: )`f A �S1�/J s thphone Number: <br />Facility name: b�C1 Facility Address: <br />Hazardous substance found in the secondary containment: <br />Quantity: \/ , L(( P Concentration: n) <br />Description of,the actions taken to control and clean up the release: <br />The method and location of disposal of the released hazardous substance: <br />Description of actions taNi to repair th UST and to prevent future releases. Attach a copy of the <br />� <br />maintenance receipt: , �-5i -� ,' -\ /2,�f jy 2::_ C f N� 0 61 <br />Describe <br />� how the monitoring system <br />_was reactivated after <br />rrrepairs or replacement: <br />-!` �t-- I n / i, rr r'`�7� ° d�T�'�-� �G o �) Ci 1'l /�% /� M D�' <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 />