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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s* ov.or /c/eehd <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. U 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. U F <br />AND <br />4. The release does not cause deterioration of the secondary containment. F <br />If all conditions above are not fulfilled you must report the release to the San Joaquin County <br />Environmental Health Department and jother agencies as appropriate. Date of release: <br />Operator's name: ,u�iry2 I(�1(,�li� Phone Number�a2c3) S24a -1105 <br />Facility name: Nflj(00 %T NIS d� Facility Address: 10&E Tro IN � <br />Hazardous substance found in the secondary containment: <br />Quantity: ] Concentration: Dtood <br />Description of the actions taken to control and clean up the release: <br />rC4 �306u Ix i it <br />,100 r, 0 Ca v-QD bCAA �, (-A KV i o rl 6b, corms 1 t - <br />The method and location of disposal of the released hazardous substance: i�A' <br />Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the <br />maintenance receipt: j�(himo a'- (P�o'��' 4 � ml- ��11nG� WC 11 <br />Describe how the monitoring system was reactivated after repairs or replacement: <br />,, 11 <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 />