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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 E I V <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />DEC 2 9 2014 <br />RECORDING REQUIREMENTS <br />FOR UNAUTHORIZED RELEASES ENVIRONMENTAL <br />IJGQITU r1CDADTAACNIT <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. <br />F <br />AND <br />2. The release has not escaped the secondary containment. <br />F <br />AND <br />3. The release does not increase the hazard of fire or explosion. <br />F <br />AND <br />4. The release does not cause deterioration of the secondary containment. <br />6 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. Date of release: `% - -LY / Z <br />Operator's name: n Z- A 0 0/'--7( K I Phone Number: C y 2/ CA h l t e L143 L- e <br />Facility name: F L/1 , G/ t -/ C/ 4 E I/ r u my Fac'�fity Address: 2 P' <br />--t7 ,� <br />Hazardous substance found in the secondary containment: 0/J a <br />Quantity:y /\I I; C/1J j Concentration: �y �%}y �� f e C' <br />Description of the actions taken to control and clean up the release: <br />The method and location of disposal of the released hazardous substance: _ <br />Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the <br />maintenance receipt: <br />t,_2�� <br />Describe how the monitoring system was reactivated after repairs or replacement: <br />C a L L C4 7r if cdi t t/ z it r e, r r 0.7 <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 />