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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si og v.oru/end RECORDING REQUIREMENTS FOR UNAUTHORIZED RELEASES An owner or operator is required to record all releases from the primary containment, as approved in this facility's Response Plan. This form may be used to meet the recording requirements* if all of the conditions below are true. 1. The owner or operator can clean up the release from the primary containment within 8 hours after the release was detected or should have been detected. O F AND 2. The release has not escaped the secondary containment. T AND 3. The release does not increase the hazard of fire or explosion. T AND r 4. The release does not cause deterioration of the secondary containment. T, If all conditions above are not fulfilled you must report the release to the San Joaquin County Environmental Health Department and other agencies as appropriate_ Date of release:" &coo 2 %:�Z -o )� Operator's name:_,, ` Phone Number: C Facility name: C Facility Address:\ o, 7,7K Hazardous substance found in the secondary containment: Quantity: Concentration: z Description of the actions taken to contr I nd clean up the rePase' 11 C I p oimk ` - Y The method and location of disposal of the relea a azardous su stance: 1n ja Description of actions taken k`to repair the UST and to prevent future releases. Attach a copy of the maintenance receipt: Describe how the monitoring system\was reactivated after repairs or replacement: Attach printout from continuous monitoring Retain this document with your monitoring *See the Califomia Code of Regulations, Title 23; 25294 for further requirements. maintenance receipts, manifests, photos, etc_ for review during the annual inspection by our department. 2651 and California Health & Safety Code Section