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0 0 <br /> RECENED <br /> SAN JOAQUIN COUNTY 2018 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sjgoV.orp/ehd ENV RONMIEN TAi_ <br /> F-F!,,s! ?T BENT <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 rl <br /> within 8 hours after the release was detected or should have been detected. T F <br /> AND (T� <br /> 2. The release has not escaped the secondary containment. U 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. T F <br /> If all conditions above are not fulfilled you must report the release to the San Joaquin Count <br /> Environmental Health Department and other agencies as appropriate. Date of release: <br /> Operator's name: Phone Number: <br /> Facility name: 0 2�0�e� Facility Address: rte' s <br /> Hazardous substance found in the secondary containment: \ <br /> Quantity: �_` _ Concentration: <br /> Description of the actions taken to control and clean up the release: <br /> ' <br /> CKAV <br /> The method and location of disposal of the released hazardous substance: 4 IQ <br /> -41 <br /> Description of actions taken to repair the UST and to prevent future,releases. Attach a copy of the <br /> maintenance receipt: i <br /> Describe how the monitoring system was srreactiv ted fter repairs or pI Qment: <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 /> 1 <br />