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0 SAN JOAQUIN COUNTY 6 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave., Stockton, CA 95205-6232 <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 clean up the release from the primary containment , <br /> within 8 hours after the release was detected or should have been detected. TO F <br /> AND l <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. CT 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: j V(4` 14'U V1 Phone Number: 2 C <br /> Facility name: , Facility Address: <br /> t ii chi./C-14 Z`l 1 <br /> Hazardous substance found in the secondary containment: d <br /> Quantity: C l.A Concentration: LAA"A WaVAe � i' j� <br /> L <br /> Description of the actions-taken to control and clean up the release: r NOV $ 4 2015 <br /> �� ai (��l (.�(,� i(�1 Yui 2-f�►`�lu � ru 1'YI <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> The method and location of disposal of the released hazardous substance: Zz S kl` <br /> t4 2 <br /> Description of actions taken to repair the UST and to prevent fut re releases. Attach a copy of the <br /> maintenance receipt: 62, vykaliflWwu, \,Uy VI( d �11- a V-lie P CD ILS <br /> V,VIW V97e4'M! � <br /> Describe how the monitoring system was reactivated after repairs or replacement: <br /> jCLl Kt I(aiI W(L f. uuc &&A iLe, �u'✓t U I Ntilt+16' S aj/-C <br /> V L <br /> [V) KAVj jJt*�O� a G W I a 0 G1 r Wyf fig- »l&i f1 of- 5�'to s oy_� <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 />