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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN 1 <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> RECORDING REQUIREMENTS <br /> FOR UNAUTHORIZED RELEASES <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 clean up the release from the primary containment <br /> within 8 hours after the release was detected or should have been detected. F <br /> AND <br /> 2. The release has not escaped the secondary containment. F <br /> AND (D <br /> 3. The release does not increase the hazard of fire or explosion. O F <br /> AND <br /> 4. The release does not cause deterioration of the secondary containment. F <br /> If all conditions above are not fulfilled you must report the release to the San Joaquin County <br /> Environmental Health Department and other agencies as appropriate. <br /> Operator's name: Phone Number: <br /> Facility name: F 10►!� e;t y C V%., e^o1 Facility Address: 6 y-4l <br /> Hazardous substance found in the secondary containment: hon e <br /> Quantity: Concentration: <br /> Description of the actions taken to control and clean up the release: <br /> Call � cQrr, 2 oQj Tr <br /> The method and location of disposal of the released hazardous substance: .; GL-n J7ru.� <br /> 6 y to e TGA L ang a- . <br /> Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the <br /> maintenance receipt: Via. <br /> Describe how the monitoring system was reactivated after repairs or replacement: <br /> �a,(l LL east, r2,o d Te "Ze <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 />