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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.sjgov.org/ehd <br />RECORDING REQUIREMENTS <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. F <br />AND <br />2. The release has not escaped the secondary containment. O F <br />AND OT <br />3. The release does not increase the hazard of fire or explosion. 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 County / / <br />Environmental Health Department and other agencies as appropriate. Date of release: 1 I t3 l t 0 <br />Operator's name <br />U ��- Z,3,J Phone Number: `t 7 Z - 7 Z -`l - S: -(o 7 <br />Facility name: PtD bA- >J 7�J ecility Address: 13 7SSz' k) �t <br />� '3'��4a <br />V rocs <br />e��9 i, C-4- . `1 i Z ti 0 <br />Hazardous substance found in the secondary containment: �Z,,�`D C>� t (�;--05 eZ-- <br />Quantity: `iz- e_ Concentration: <br />Description of the actions taken to control and clean up the release: <br />L(SL- 4) Acys 04LD (DASD —(V C L trW,) <br />The method and location of disposal of the released hazardous substance: 4f5So2. tL;O <br />AD A - L4- A- r6;0 l! l-1 LJ T- w S NA J Z int <br />Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the <br />maintenance receipt: v i"b 0 0 }-uuuc.� s (- f C Z - <br />^ <br />.ti v a1 <br />,-I-- ) rra-cl- <br />Describe how the monitoring system was reactivated after repairs or replacement: <br />5 c= Qj S© i- ` 5 ,mac` - a n -i :�-� ^..J �+-Lfk-V VV , RA o - xt LZ,� <br />0 f-0 jv o r- i i --G 0161 6n prLV A-%'` <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 />