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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT , Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj ov.org/ehd SII ;. � Wi i :41110 FAII 1 0 0=1 11-4 R EF—A-1 An owner or operator is required to record all releases from the primary containment, as approved in this facility's Response 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 *thin 8 hours after the release was detected or should have been detected. f F 2 Nphe release has not escaped the secondary containment. F AND release does not increase the hazard of fire or explosion. T F AND N 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 L. i V Phone Number: Facility name: Facility Address: Ui . da im 2c_-z_tic- i8 cg Hazardous substance found in the secondary containment: Quantity: C LJPS Concentration: jos 0�0 Description of the actions taken to control and clean up the release: t)J-e 61 The method and location of disposal of the released hazardous substance: Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the mnintPnnnnp rPCPint- 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.