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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj oqy.o - /rg. ehd <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. F <br />If all conditions above are not fulfilled you must report the release to the San Joaquin County 1 { <br />Environmental Health Department and other agencies as appropriate. Date of release: q 1 1,3 It o <br />Operator's name: U (,kAl- Z. c,,J Phone Number: ct 7 - " 7 2--`7 -S,1,'?i <br />Facility Warne: - " b� � g " F acility Address: t Vy' &; -0 V <br />Hazardous substance found in the secondary containment: 0;--C 5c - <br />Quantity: V1 g Concentration: <br />Description of the actions taken to control and clean up the release: <br />L -t 5eu) <br />The method and location of disposal of the released hazardous substance:t<�z <br />(� Aar . , G � h-• A-- a r `g t,.a i:. ,L_ ' t" F-4-4— <br />Description <br />4 -4 - <br />Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the <br />maintenance receipt: : �_ 4y=c; 'l -t f?:t1.�t-�4LA s ( rZ C <br />eo is , 1, b 1 Ai. > C iLo— 0-14 yx°.f:- A �! <br />Describe how the monitoring system was reactivated after repairs or replacement: <br />f r <br />.;, L 7 AA"- a Q t Z e - <br />o i:4,) . a ae i 9 OL-� it cl t i 6r -d- Pry <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 />