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Dec 15 14 09:50a Mid Valley Consulting 530-749-9892 p.1 <br /> Dec 11 14 07:45a Mid Valley C3179ulting o <br /> 530.749-9892 P.1 <br /> I <br /> RECEIVED SANTAL HEALTH <br /> DEPARTMENT ENVIRONMENTAL HEAt.TN DEQARTtdENT <br /> 1858 E. Hazelton Ave.,Stockton, CA 95205-6232 <br /> DEC 15 2014 Telephone:QW)468-3420 Fax_(209) 468-3433 Web.www.sigov o rt+eha <br /> RECORDING REQUIREMENTS4 <br /> ENVIRONMENTAL HEALTH FOR UNAUTHORIZED RELEASES �' __ �y y <br /> DE,, r. <br /> An owner o-operator is required to record all releases -rom the primary containment, as a riv ." <br /> in <br /> this facility's Response Plan- This form may be used to meet the -ecording requiremenis' f all o the <br /> conditions below are tme- <br /> I. The owner or operator can dean up the release from the primary containment /1 <br /> i AN within 8 hours after the release was detected or should have been detected. t T / F <br /> AND he release has not escaped the secondary containment. <br /> 3- The release does not increase;he hazard of fire or explosion. r <br /> AND F <br /> 4. The.release does not cause deterioration of the secondary containment. <br /> T F <br /> fall conditions above are not fulfilled you must report tho release to the San Joaquin Countv(`-- <br /> Environmental Health Department and other agencies as appropriate. Date at release: <br /> Operatcr's nam13w,e: + pp er/ Phone Number'.2Ce <br /> Facility name: oxry-- / i/lty� + Cfiet)FacilityAddress: If/'l 014 ck �;LEnt <br /> Hazardous substance found in the secondary containment: � +�£ S T-L– <br /> Quamity:_ /-�}� .rr Concentration-_ /J10 '_— ----- <br /> Descri on of the adtaken fo control no des u release; / <br /> )J tSrc w ('�r14 , / A<SS/p g; r Crpf?t . <br /> ( �1 �I 'E-5—�7i�c€!i <br /> A9 T <br /> D1 mefho and location of disposal. 'of the released hazardous substance: <br /> fid" <br /> Description of actions.aOP tc repair T�cand to pr t future releases. Attach copy of the <br /> -tog receipt (� � /2 <br /> Describe how the monitoring system was reactivated^��7{�er/.fepairs or replaoemea <br /> (J ® CCx c-r Ic-L +£�}G`f_ GJv{.� !�o-t" <br /> Attach printout from con nuous monitoring system,maintenance receipts,manifests, <br /> Retain th's document with your monitoring retorts for review during the annus,inspection by our department. <br /> 'See the California Code of Regula:lons, Title 23,Section 2651 and Callfornia�eaith&Safety Code Section <br /> 25294 for further recIArements. <br />