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SAN JOAOUIN Environmental Health Department <br />C,0UI\J1Y <br />California Accidental Release Prevention Program <br />De -Registration Form <br />7. Select (Check) Reason for De -registration: <br />❑ Source reduced inventory of all regulated substances below threshold quantity(ies) <br />❑O Source no longer uses any regulated substance <br />❑ Source terminated operations <br />❑ Source is relocating <br />❑ Other: (explain below) <br />Use of Chlorine gas was discontinued after the on-site supply was exhausted and <br />process treatment was changed to use an alternate liquid chemical Sodium <br />Hypochlorite. <br />8. List of Regulated Substances) Being De -registered: <br />De -registered Substance(s) <br />9. List of Regulated Registered Substance(s): <br />Regulated/Registered <br />substance(s) <br />CAS Number <br />Current Max Quantity (lbs.) <br />1- <br />Chlorine <br />1- <br />2- <br />3- <br />4- <br />3- <br />9. List of Regulated Registered Substance(s): <br />Regulated/Registered <br />substance(s) <br />Program <br />Level <br />CAS <br />Number <br />Current Max <br />Quantity (lbs.) <br />NAICS <br />Code <br />1- <br />2- <br />3- <br />4- <br />10. Select the following <br />documents to attach as a proof of <br />removing <br />the de -registered <br />substances) <br />❑ Manifest <br />❑ Bill of Lading <br />❑D Photos <br />Page 2 of 3 <br />