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• • <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.sjgov.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. V F <br /> AND <br /> 2. The release has not escaped the secondary containment. '" F <br /> AND C <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 Coy ,ty <br /> Environmental Health Department and other agencies as appropriate. Date of release: <br /> '� <br /> Operator's name: t &(4& SfVrMtk Phone Number: <br /> 1510 3gp <br /> Facility name: �� g Facility Address: V�--l3v► <br /> ``� 9s3►� <br /> Hazardous substance found in the secondary containment: �I f} ( <br /> Quantity: CLY Concentration: <br /> Description f the acti s t en 4 control and clean up the release: <br /> elm lat <br /> The me hod and loca ion of disposal of the,r9leased hazardous substance• <br /> Description of actions taken to repair the UST.and to preye t future releases. Attacb a,copy of the <br /> maintenance receipt: "D `_ tm 'I aievick Y <br /> Describe how the monitoring system was reactivated after repairs or replacement: <br /> 2&k L r aU arQ. <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 />