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03/08/2017 11:37AN FAX 2098236719 ONE STOP MARKET CHEVRON 1@0004/0006 <br /> 0 0 <br /> SAN JOAQUIN COON-ry <br /> ENVIRONMENTAL HEALTH OEPAR-rMENT RECEIVED <br /> 1868 E. Hazelton Ave,, Stockton, CA 95205,6232 <br /> Tel hone.(209)468-3420 FOX. (209)4683433 Web:Www <br /> mwusaowgra/ebdl� 0 8 2017 <br /> RECORDING REQUIREMENTS ENVIRONMENTAL HEALTM <br /> FOR UNAUTHORIZED RELEASES DEPARTMENT <br /> Ar owner or operator is required to record all releases from the Primary containment, as approved in <br /> M 5 facility's Response Plan. This form may be used to meet the recording requirements* if <br /> cc-iditions below are true. all of the <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. <br /> AND UT F <br /> 2. The release has not escaped the secondary containment.nment. (9 F <br /> 3. The release does not increase the hazard of fire or explosion. �,—% <br /> AND (T) F <br /> 4. The release does not cause deterioration of the secondary containment. \!J F <br /> If a I conditions above are not fulfilled you must report the release to the San Joaquin County <br /> Enfironmental Health Department and other agencies as appropriate. Date of releaser-1 L <br /> Op wator's name: Phone Number: <br /> Fa ilii y name: l�y Y, $/r6 r)) <br /> __4j Facility Address:- 1vNa-%—tlpao- <br /> Ha,ardous substance found in the secondary containment:___D L±LS <br /> Qu ntity: -- geALjn e <br /> Concentration:-----1p,,-.-L <br /> Dec,cription of the actions taken to control and clean up the release: <br /> The method and location of disposal of the released hazardous substance: <br /> j, <br /> Des -,ription of actions taken to repair the LIST and to prevent future releases. Attach a copy of the <br /> mai r tenance receipt:__ <br /> Dew ribe how the monitoring system was reactivated after repairs or replacement: <br /> Attar i printout from continuous monitoring system, maintenance receipts, manifests, photos, etc. <br /> Retai 1 this document with your monitoring records for review during the annual insPection,by our department. <br /> *See he California Code of Regulations,Title 23, Section 2651 and California Health&Safety Code Section <br /> 252.011,f for further requirements, <br />