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0,6/25/2012 11:03 2093344684 04297 P.003 /003 SAN JOAQUIN COUNTY ENmRoNmEmTAL HEALTH DEPARTMENT 600 East Main Street,Stockton, CA 95202-3029 Telephone:(209) 3420 Fax:(209)468-3433 Web: v. ! hd RECORDING REQUIREMENTS FOR UNAUTHORLZEDRELEASES An owner or operator is required to record all releases from the primary containment, as approved in this facility's Response Plan. This form may be used to meet the recording requirements'* if all of the conditions below are true. 1. The owner or operator can dean up the release from the primary containment within 8 hours after the release was detected or should have been detected. T F AND CT) 2. The release has not escaped the ndary containment. F AND 3. The release does not increase the hazard of fire or explosion. CTJ F AND. 4. The release does not cause deterioration of the secondary containment. UT F If all conditions above are not fulfilled you Mug re ort the release to the San Joaquin County Environmental Health De nt and other ag ni as appropriate. Date of release. ratoes name: i one Number. — - - // Facility name: — _ � Faci*Address: Hazardous substance found in the secondary containment: Quantity: �h.. Concentration: Description of the actions taken to control and clean up the release: c.P T V-- The -The meth and location ofd' I o€the relea hazardoussubstance: ;� Description of actions taken to repair the T and 0 prevent future leases. Attach a copy of the maintenancereceipt:. Describe how jha monitoring system was reactivated after repairs or replacement: VIA tcodn Attach printout from continuous monitoring syslem,numilenance rempts,manifests,photos,etc. Retain this document with your monitoft records for review during the annual inspection by our *See the California Code of Regulations,We 23,Section 2657 and California Heafth&Safety Code Section 25294 for further requirements.