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SAN JoAawm COUNTY <br />ENMRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax., (209) 468-3433 Web: Mffl8L.sjjgo_v.gV—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 in <br />within 8 hours after the release was detected or should have been detected. UT F <br />AND <br />2. The release has not escaped the secondary containment. (D <br />AND <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. <br />If all conditions above are not fulfilled y—gy must report the role -460 to the San joaquin County <br />Environmental Health Department and other agericies as appropriate. Date of release: <br />Operatoes name- tjj��M tW &ItAg�.. Phone Number-,_,)Vq-9a5"-CTq3 <br />Facility name: 1U'-Jh"?A4 gaa� Facilfty Address: 13 ffp-D-C- V—g i = vc' o, <br />Hazardous substance 1bund In the secondary containment: D=5 f5u <br />Quantity: Concentration <br />Description of the actions taken to control and dean up the release: <br />50 Ag 51- <br />-'s P� 4, C <br />The method and location of disposal of the released hazardous substance: <br />Eft I &P P14T <br />jj&Z _jMAZ f,)�L&U&M Mg <br />. j <br />Description of actions taken to repair the UST and to prevent future releases, Attach a copy of the <br />maintenance receipt. <br />BAMPI <br />Describe how the monitoring system was reactivated after repairs or replacement: <br />ma- als <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 Calftmia Code of ReguMions, Title 23, Section 2661 and Caloomia Health & Safety Code Section <br />25294 for further requirements. <br />