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SAN JOAQUIN COUNTY RECrl\/ED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 AUG z�14 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.s'gov.org/ehd <br /> RECORDING REQUIREMENTS ENVIRONMENTAL HEALTH <br /> FOR UNAUTHORIZED RELEASES DEPARTMENT <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. F <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. TO 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:_ _ <br /> Operator's name:j,t>•k"[(Q Cffl�tjS U,(, Phone Number: $lri5• <br /> Facility name: � i ,'�1r�� ���---Facility Address: ISO17A. <br /> Hazardous substance found in the secondary containment: M i-4- <br /> Quantity: 13mecjkp5, Concentration: }j <br /> Description of the actions taken to control and clean up the release: <br /> l <br /> Ali i4 <br /> reMM8 ttt�d�lt�rtd in hr�, ri !� �►A.S�CLc� -4f• <br /> The method and location of disposal of the released hazardous substance: x,,S <br /> efia,S mak, amm mi-y— <br /> Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the <br /> maintenance receipt: N( <br /> L <br /> Describe how the monitoring system was reactivated after repairs or replacement: <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 />