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RE <br /> 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 v <br /> RECORDING REQUIREMENTS DEPARTMENT <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. T F <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. T 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 Coun y <br /> Environmental Health Department and other agencies-as appropriate. Date ofrelease: <br /> ��et 11411 <br /> Operator's name: f t^ td it _Phone Number: <br /> e: #6mmg <br /> __x 4 tic <br /> Facility nam 13�.Facility Address, /ol 10 <br /> CAIS-allo <br /> Hazardous substance found in the secondary contalnment:_I&Wuip_,����Tp sump <br /> Quantity: - 1a-nA4d, Concentration: 3LCg&DE PrCY&Lli F-A4P-,- <br /> Description of the actions taken to control and clean up the release: <br /> I A L,$- <br /> The method and location of disposal of the released hazardous substance: <br /> ullu': 'Li,iii Min Irl, -e <br /> 11 Ili VC, <br /> 117.1"1 ig,�l 3I,P11AC11j, <br /> W 21 2ri? somp- <br /> Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the <br /> 00 <br /> maintenance receipt: <br /> all <br /> 1*#W VOA40 <br /> Q kA <br /> 14 <br /> Describe how the monitoring system was reactivated after repairs or replacement: <br /> iIIA-1 <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 2661 and California Health&Safety Code Section <br /> 25294 for further requirements. <br />