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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 �I � <br /> Telephone: (209)468-3426 Pax: (209)468-3433 Web:www-sigov.orale <br /> RECORDING REQUIREMENTS MAR 0 7 2016 <br /> FOR UNAUTHORIZED RELEASES ENVIRONMENTAL <br /> HFAi TH MMARTAfich T <br /> An owner or operator is required to record all releases from the primary containment, as approved in <br /> j this facility's Response Plan. This form may be used to meet the recording requirements* if all of the <br /> i conditions below are true. <br /> 1. The owner or operator can cleanup the releasefrom the primary containment ,�y <br /> within 8.hours after the release was detected or should have been detected. U F <br /> AND <br /> 2. The release has not escaped the secondary containment. F <br /> AND <br /> 3, The release does not increaselthe hazard of fire or explosion, F <br /> AND <br /> 4. The release does not cause deterioration of the secondary containment- F <br /> If all conditions aboveare not fulfilled youCounty <br /> ,must report the release to the San Joaquin C <br /> Environmental Huth Department and r agencies as appropriate, Date of release: '2 1 to <br /> Operator s name: <br /> ' v Phone Number:_ . �j (t�•-571 <br /> Facility name � � 4 'Vt v� t N� ' Facility Address <br /> j Hazardous substance found in the secondary containment: <br /> Quantity: l 6f 16 Concentration: =��,/h� Lr/ <br /> Description of the actions taken to control''rid can up the release: <br /> �j den*,, L+ <br /> i <br /> The method and location of disposal of the released hazardous substance: <br /> j Gr+1 <br /> s� <br /> Description of actions taken to repair the UST and ttypreve t futurereleases. Attach a copy of the <br /> maintenance receipt: p�{L�r ���� -1"7- X , <br /> Describe ow the moniCoring system was reactivated after repairs or replacement: <br /> 7 S All 6,Z f 44�2c ZZI loz & <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 Califomia Code of Regulations, Tdle 23,Section 2651 and California Health&Safety Code Section <br /> 25294 for further requirements. <br /> 800/ E00'd 9L8L# $89H�££60Z 6Z:ZL 910Z/LO/£o <br />