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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT RLGoEIVED <br /> 1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehdAR 3 O Z017 <br /> RECORDING REQUIREMENTS ENVIR©NMENTALHEALTH <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. C__% F <br /> AND r� <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. T 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: <br /> Operator's name r�,� �i�S / Phone Number. p <br /> Facility name: 6ncrr vs L1 `� Facility Address: cY06 a - t br"� <br /> Hazardous substance found in the secondary containment: T5 -A f--` <br /> Quantity: It Or AS Concentration: <br /> D/e}scr�Ttion of the actions taken to control and clean up the release: t <br /> et elf - L4 In op eo Ile <br /> Qa G f \ e 0 <br /> ,^ nI., �L <br /> The method and location of dis osal of the released hazardous substance: <br /> Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the <br /> maintenance receipt: U),i ; ,� o r� I" f.)C& 4", - <br /> DesHibe how the monitorin system was reactivated after repairs or replacement. <br /> 1�J �, ,— l ' - J' P <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 />