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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.segov.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. �T F <br />AND <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. 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. Date of release: <br />Operator's name: 5 �"� ( JLC Phone Number: jo-9- 7& <br />Facility name: (214t7lu) tcK 64 .-It Facility Address: <br />Hazardous substance found in the secondary containment: <br />Quantity: I LrAIIF Concentration: (A� , <br />(-)/ry 1p <br />Description of the actions taken to control and clean up the release: <br />(j L(L / �lC i P � I �r r c.�A � I cfU �E )ejE 5K (� ( �l r00. 0 <br />The method and location of disposal of the released hazardous substance: <br />(-Lt rI L 6 S 15 40c A (C I a v -r 4-o l l vM <br />Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the <br />maintenance receipt: W U -k- kAaye 10 -CAA 1 rl tGt-1 1c (2-" l -k DR GCSE r)f <br />Q.r rn w.A r ),-i -sao.P q <br />Describe how the monitoring system was reactivated after repairs or replacement: <br />� t L (.X Sks 7-1, aANII r) t iL k4<qy e <br />� 1 I <br />Ell <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 />