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10%17/2010 THU 8: 51 FAX 2094683433 SJC EHD 0002/006 <br /> t <br /> 1 <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.sigov.or /g 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. ;P F <br /> AND <br /> 2. The release has not escaped the secondary containment. V F <br /> AND <br /> 3. The release does not increase the hazard of fire or explosion. a" 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 app <br /> opriate. Date of release: <br /> Operator's name: � <br /> � /LD l3� l Ph 'e Number: <br /> fjA <br /> Facility name: Z�' 'Wo Facility Address: <br /> Hazardous substance found in the secondary containment: _ /V1 <br /> Quantity: 4g 12 Concentration: <br /> Descriptio of the actions taken to control and clean up the release: <br /> - T <br /> Com--✓ 1 (�''�''� � �,. i __� <br /> The method and location of disposal of the released hazardous substance: <br /> 1Z v <br /> Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the <br /> maintenance receipt: <br /> Describe how the monitoring system as reactivated after rep�irs�or <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 />