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11/26!2008 14 :35 FAX 16003/00 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT' <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone. (209) 4.883420 Fax:(209)468-3433 Web:www.5i ov.o j2hd <br /> RECORDING REQUIREMENTS <br /> FOR UNAUTHORIZED RELEASES �r <br /> An owner or operator is required to record all releases from the primary containmen , 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 <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. <br /> AND <br /> 4. The release does not cause deterioration of the secondary containment. F <br /> If all conditions above are not fulfllled You must rAaort the release to the San Joaquin County <br /> Environmental Health Department and other agencies as appropriate. <br /> Operator's name: Phone Number: 3$"9►-- )� � <br /> Facility name: f ,$5� 6,�i/0, 4/Facility Address: 6 w 11- <br /> T lt'r4N [►�- 4S.2aC <br /> Hazardous substance found in the secondary containment: / " el <br /> Quantity: f.F cZ Concentration: _ <br /> Desai tion of the a 'ons en control nd clean up the release: <br /> iG TOG e • <br /> The method and lo}/cationf disposal of the released hazardous substance: <br /> f rG <br /> Description of actions taken to repair the UST ato prevent future releases. Attach a ropy of the <br /> m intenance receipt: 3;114! -117- 17-1 -�ka K, Ij 1�e ti <br /> Descrj,be how the monitoring systom was reactivated after repMrS or replacement: <br /> Y c-k ci <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 Coda Section <br /> 26294 for further requirements. <br />