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Parkwood Gas&Food 2 98888157 p.4 <br /> RNE-CEIVIM <br /> 0-M <br /> SAN JOAQUIN COUNTY JUL 2 5 `018 <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/eh4NVIPt?f°uMENTAL <br /> F#EAtT le EIE 1`. TMENT <br /> RECORDING J ENTS <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 cleanup the release from the primary containment <br /> within 8 hours after the release was detected or should have been detected. ,T F <br /> AND u <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. l 7� p <br /> AND `.1 <br /> 4. The release does not cause deterioration of the secondary containment OT 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: —7-5 - le <br /> Operator's name:��t'SS� 1'[W1 ee-P)C, Phone Number: 2�j®, —2 i 5 - U( Z L� <br /> Facility name: oc4 Facility Address: (2/(� ,G l�Kllwr: tl <br /> 5�v� t<`i-cam C✓�' �tSz/t <br /> Hazardous substance found in the secondary containment:_aGkS <br /> Quantity: Concentration: <br /> Description of the actions taken to controlnd clean up the.release: <br /> G.aS Wca S P��i�() (sv+ 0—"CA i h <br /> The method and location of disposal of the released hazardous substance:MhLr- Ile,Lam• iG,Ucf <br /> Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the <br /> maintenance receipt: oc-rte •=5 ��c l{� �� j-� <br /> Describe how the monitoring system was reactivated after repairs or replacement: <br /> t'-c h ;o t eve. <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 /> Received Time Jul. 25. 2018 10:46AM No, 3918 <br />