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SAN JOAQUIN COUNTY OREic v ED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 MAY 2 8 2013 <br /> Telephone: (209) 468-3420 Fax:(209)468-3433 Web:www sigov.orq/ehd <br /> SAN <br /> ENVIRONMENTALTM <br /> RECORDING REQUIREMENTS HENMFIONMEALTH TALT <br /> FOR UNAUTHORIZED RELEASES <br /> MEN <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 cleanup the release from the primary containment <br /> within 8 hours after the release was detected or should have been detected. T F <br /> AND T F <br /> 2. The release has not escaped the secondary containment. <br /> ANDT F <br /> 3. The release does not increase the hazard of fire or explosion. <br /> ANDT F <br /> 4. The release does not cause deterioration of the sedondwy containment. <br /> If all conditions above are not fulfilled you must report the release to the San Joaquin County <br /> Environmental Health Department and other agenci��es��as appropriate. Date of release: � <br /> Operator's name: _ �2j�;L 'hone NumberL -- — w� <br /> Facility name: A P Facility Address, ] <br /> n a <br /> Hazardous substance found in the secondary containment:_ AiciN 5�-- <br /> Quantity: ����'���Concentration; <br /> Description of the actions taken to control nd clean upe release: <br /> o T��l' tam—� <br /> The-method and location of disposal 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:- <br /> D rib itor' system was reactivated after,repairs or replacement <br /> "- <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 />