Laserfiche WebLink
SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s'gov.org/ehd <br />101 <br />r F-11119 : 101 1N PA r4 211 <br />1, r <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. T TF <br />AND <br />2. The release has not escaped the secondary containment. T 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. CJ F <br />If all conditions above are not fulfilled ygu must re ort the release to the San Joaquin County <br />Environmental Health Department and other agencies as appropriate. Date of release: <br />Operator's name Ktit' (JA L4 Phone Number:_ —$ bS— gc <br />Facility name: &"yl&v,ea 77W JT11C Facility Address: 1w 0%&4?4( <br />Lam.!'" Cly °ta�33 <br />Hazardous substance found in the secondary containment: <br />Quantity: p Concentration: W c.,or IN <br />Description of the actions taken to control and clean up the release: <br />�f t,aA S 1L5py 6,D `i o �agj)e)v. L. AA( <br />ON Tk e cine <br />The method and location of disposal of the released hazardous substan <br />juL 18 2w -- <br />Description of actions taken to repair the LIST and to prevent future rel ach a copy of the <br />maintenance receipt: MENTAL Hj:-A <br />Describe how the monitoring system was reactivated after repairs or replacement: <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 />X <br />