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F-WWONVENlTK MfALTH UEPARTMENT <br /> B iaat Main Street,4odoon, CA 95202-WZ' <br /> Tolophorre:(20V468-3420 fax.(2QP)469.3439 Web:wweu.afa4v.orcUehd <br /> RECORDING REQUIREMENTS <br /> FOR UNAUTHORIZED RELEASES <br /> An owner or operator Is required to record all relapses from the primary containment, as approved in <br /> this fac lity's Response Plan. This form may be L*d to meet the recording requirements' if all of the <br /> condition below are true <br /> 1. The owner or operator can clean up the tease from the primary containment ; <br /> within 8 hours after the release was Clef ed or should have been detected. .T F <br /> AND <br /> 2. The retease has not ascaped the secoo*ry containment F <br /> AND <br /> 3. The release does not increase the ha2,*of free or explosion. ��F <br /> AND , <br /> 4. The rebase does not cause dateriora"of the sawr4try containment. F <br /> If all conditions above are not fulfilled Youto the Sart Joaquin County <br /> �rwkormental Health Department and other agent as appa(e, Date of release: <br /> Operator's name: �' f 3S� tt a. Phone Number y¢r• f -ez <br /> Faceity name: t}la+tt A o- ,+.rick w FacilRy Address: <br /> -mitardous substance found in th secondary as"nmettt: lel.r5 !� rh 16,*f+rf <br /> Quantity `/c Concentrarti4 S'y" 0 <br /> Descn pbW of the actions taken to cvdml and up me tf-i1100s6: <br /> ;LIS a /-1 Jit( 17 :V, S� F�'.a // 1d-r'ltsi <br /> zkc do /)' f7 <br /> The tnattod anQ,7tton of disposay of the re"hmxk)ua substarxw: <br /> Description of actlons taken to repair the UST and Iif prevent rutr rereases. Attach a copy M thilk <br /> malnterance receipt <br /> :eschbe how the mondo*Q system was after repairs or replacement: <br /> r-1 /.'-?4 Y >:fAi 'r V1 <br /> Anacn printout from continuous monitoring system.aWmile sante recet^ manifests,photos,otc. <br /> Ulaln this dloraumorn with your monitoring retards for redrew dtring the anmow inspection by our cepartnient. <br /> ies the CallfomW Code of Regulaoons. Title Z3, Sectk*2651 and California Health b Safaty Code*Athan p <br /> "5294 for furher requirements. <br /> Gci, 0 0 2011 <br /> cNVIIRONMENTAL <br /> .;:.A LTH QEPAITMENT <br />