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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <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 q) <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 County <br />Environmental Health Department and other agencies as appropriate. Date of release: e,.—{t)-A <br />Operator's name: <br />Phone Number: <br />Facility name: B, -A V T1 u.Qf� T�t-i�� Facility Address: 3&33 �t�� CfeeM t�° <br />Hazardous substance found in the secondary containment: E. 4k r � }lit u(��; ( f vu F�f -all <br />Quantity: t fit ! C4 Concentration: <br />Description of the actions taken to control and clean up the rete se: <br />U�__��S Ct._l` t �C'_1 �( j t� 0.C-1t/-JXLctcC C�It'-1f'► Ixc_ �tc ,IcLgc_-i ,/1C( ci►(� <,t C ►K'it <br />t- I ne r(ICJ-)I S " <br />ut— -N A O ff '(d [ c 9t* � f_ 1 T E at o,( <br />The method and lo71, <br />tion of disposal of the relbased hazardous substance: <br />(�,gCC1 Citi aka a- l "t:�t k` �l pit t iXA, <br />Les-12-iptilo-nnof actions taken t repair, the UST and to preve futWre <br />maintenance receipt: 4 1-vCt- u? _[ VV I -) I Wt C, i' A <br />ELV4- <br />t.J�ad l-& <br />i cbpyf the <br />✓ �ci <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 />