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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. Hazelton Ave., Stockton, CA 95205-6232 Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.s lovorg�/ehhdd R I V E D RECORDING REQUIREMENTS MAR 2 0 2018 FOR UNAUTHORIZED RELEASES E "L ft r is required to record all releases from the primary containment, as approved in W T Et 19rK%V1q �rte 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 clean up the release from the primary containment within 8 hours after the release was detected or should have been detected. T F AND 2. The release has not escaped the secondary containment. k0 F AND 3. The release does not increase the hazard of fire or explosion. T F AND 4. The release does not cause deterioration of the secondary containment. , T F If all conditions above are not fulfilled you must report the release to the San Joaquin County Environmental Health Department and other agencies as appropriate. Date of release: Operator's name: Phone Number: Facility name: Facility Address: Hazardous substance found in the secondary containment: Quantity: Concentration: Description of the actions take Q to control and clean up the release: q-jZZ\A2 — zp�� SER (!,�\Sil� R�Eic The method and location of disposal of thereleased hazardous substance: pot F= Description of actions taken to repair the,L)ST and to prevent future releases. Attach a copy of the maintenance receipt: (-, :—N�qac tom, -Iacs):—�OK L6- Describe how the monitoring system was reactivated after repairs or replacement: Attach printout from continuous monitoring system, maintenance receipts, manifests, photos, etc. Retain this document with your monitoring records for review during the annual inspection by our department. *See the California Code of Regulations, Title 23, Section 2651 and California Health &Safety Code Section 25294 for further requirements.