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SAN JOAQUIN COUNTY RE � n�('r— <br /> ENVIRONMENTAL HEALTH (DEPARTMENT 001 ���� L—. <br /> 1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.or, /q ehjkl� 3 Q 2017 <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. `f 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. 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: -�- b I <br /> Operator's name: y�o,,K 4 S ' IleL� Phone Number s -� <br /> Facility name: A C, J, _ Facility Address: V�66) <br /> Hazardous substance found in the secondary containment: + I <br /> Quantity: IQ% a r *S Concentration: <br /> V <br /> Dsc iption of the actions taken to control and clean up tie releas <br /> 0"1 <br /> re o & 'r 4. <br /> The method and lo/'cation of disposal of the released hazardous substance: a <br /> 9 �1� 1 cc 0, l d "1S 62 4 c-- <br /> Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the <br /> maintenance receipt: -l_ I'/ 2 _zr -Q <br /> 6 r'r, , ,/- <br /> Describe how the monitoring system was reactivate after repairs or replacement: <br /> Attach printout from continuous monitoring system, maintenance receipts, manifests, photos, etc. <br /> Detain 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 />