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Dec 11 1407:48a Mid Valley Consulting 53n-749-9892 P.1 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT RFECEIVED <br /> 1858 E. Hazelton Ave., Stockton, CA 95205-6232 C <br /> Tefephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.s ov.or /ehd <br /> --� <br /> RECORDING REQUIREMENTS ULC Z 1 2014 <br /> FOR UNAUTHORIZED RELEASES::"VIRONMENTALHEALTH <br /> OFP,ARTMENT <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. f T / F <br /> AND y!� <br /> 2. The release has not escaped the secondary containment. F <br /> AND <br /> 3- The release does not increase the hazard of fire or explosion. T F <br /> AND <br /> 4. The release does not cause deterioration of the secondary containment. T F <br /> If all conditions above are not fulfilled you must report the release to the San Joaquin Count <br /> Environmental Health Department and/other agencies as appropriate. Date of <br /> Operator's name: rCJm �lrp4d N t I/ )) Phone Number:_- <br /> Facility name:� t /� /4�a o K CiP tJFacility Address: / �'/6 <br /> Hazardous substance found in the secondary containment: <br /> Quantity: -_ f' 7 � Concentration:__ /1,7-94r <br /> Description of the actio s taken to control p nd clean up th release: <br /> t1mt.lg +� 't StL 4 C/£ - V/- A4 SY/2(3;nT C` A, <br /> 14 0 U g5 �✓1t�h i vu i4Z f 5 /LKt> i <br /> kd 7 -S• Tf <br /> T method,,and location of disposal of the released hazardous substance: <br /> e-z- kJ&ktoy-s <br /> Description of actions taW to repair th . T and to preyf�t future releases. Attach �copy of the <br /> maintenanc receipt:_ u p /Z KPdI4/it 0) 7tcrz,� <br /> Describe how the monitoring system was reactivated fterfepairs or replacement: <br /> O ! die t ��, . 1L1L' 6G� Luv� s nsr � .coc�q,b <br /> - i .-�fsf �..yam ,✓� <br /> Attach printout from con /n s 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 Cali€orria Health &Safety Code Section <br /> 25294 for further requirements. <br />