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SANJOxQDIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />G0OEast Main Street, Stockton, CAR5202-3020 <br />Telephone: /2O0\468-342OFax: (2O0)488-3433Web: <br />An owner or operator is required to record all n*|eaaea from the primary containment, an 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 oroperator can clean upthe release from the primary containment <br />within 8 hours after the release was detected or should have been detected. nl' F <br />AND -~~ <br />r—" <br />2. The release has not escaped the secondary containment. \/ | F <br />AND <br />3. The release does not increase the hazard offire orexplosion. /T� F <br />/ <br />AND — <br />4. The release does not cause deterioration ofthe secondary containment. /~�^. F <br />Ifall conditions above are not fulfilled you must report the release 0othe San Joaquin <br />Environmenha|Health Department and other agencies anappropriate. Date ofrelease: <br />Operators name: Phone Number: <br />Facility name: Facility Address: <br />Hazardous substance found in the secondary containment: <br />Quantity: fl�Concentration: <br />Description ofthe actions taken tocontrol and clean uothe release: <br />The method andlooaUu of disposalofthe releasedhazardous substance: <br />Description of actions taken to repairthUST andto prevent future | Attach of the <br />Describe how the monitoring system was reactivated after repairs orreplacement: <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 />25294for further requirements. <br />