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© 0 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />6010 East Main Street, Stockton, CA 95202-30129 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sipov.orglehd <br />RECORDING REQUIREMENTS EASES <br />FOR UNAUTHORIZED <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 />. The owner or operator can clean up the release from the primary containment T p <br />within 8 hours after the release was detected or should have been detected. <br />AND T F <br />2. The release has not escaped the secondary containment. <br />AND T ff <br />F <br />3. The release does not increase the hazard of fire or explosion. <br />AND e deterioration of the secondary containment. F <br />4. The release does not caus <br />If all conditionsHeatth Departmentland other �agenciestas app opnaoteh Date of release: <br />County <br />above are not lease <br />Environmental <br />'hone Number: '- <br />Operator sname:=6 i M q 5 " <br />Facility name: Facility Address: ° C/F9.) � <br />Hazardous substance found in the secondary containment: <br />Quantity:�?u o,n <br />©Z Concentration: <br />The rcAthod and location oftdispq�al of the re <br />Description of actions taken to repair the IST <br />maintenance receipt: __JE <br />e how the monitdiring system <br />to preventfuture releases. Attach a copy of the <br />after repairs or replacement: <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 />8'd ZD72B917:01 9299TE6GOE� T iJodr3H9 00J60WW&cJ ZT:ST TT02-,LT-813A <br />