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SAN JOAQUIN COUNTY RECENED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave., Stockton„ CA 95205-6232 MAR 3 0 2017 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sjqov.onq1ehd <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. a,) F <br /> AND <br /> 2. The release has not escaped the secondary containment. F <br /> AND rrte�;; <br /> 3. The release does not increase the hazard of fire or explosion. CY F <br /> AND <br /> 4. The release does not cause deterioration of the secondary containment. F <br /> If all conditions above are not fulfilled Vou must report the release to the San Joaquin Cou�jrty <br /> Environmental Health Department and other agencies as appropriate. Date of release: �-e b <br /> Operator's name: a .,A C, � i er✓j Phone Number• <br /> Facility name: A -5 7 �— Facility Address: !�D , S. A,ftp or-T' <br /> Hazardous substance found in the secondary containment: <br /> Quantity: 4 A cc Ct i-- Concentration: A <br /> Description of thip actions taken to control and clean up the release: <br /> The method and location of disposal of the released hazardous substance: Ce /)S �., <br /> Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the <br /> maintenance receipt: r 4'r vep eoo a <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 cur department. <br /> *See the California Code of Regulations, Title 23, Section 2651 and California Health &Safety Code Section <br /> 25294 for further requirements. <br />