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0 SAN JOAQUIN COIJIM <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 96202-3029 <br />7'elephone: (209) 468-3420 Fax., (209) 468-3433 Web: www.§jg-oy.QL QW <br />gL <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 />AND <br />2. The release has not escaped the secondary containment. <br />AND of fire or explosion. <br />3. The release does not increase the hazard <br />AND <br />4. The release does not cause deterioration of the secondary containment. <br />if all condons above are not fulfilled yQu mu§t report the relean to the San Joaquin County <br />Environmental Health Department and other agencies as appropriate. <br />"t1perator's name: WR Ia ti n. f.ne Number <br />Facility name: FaCility Address: <br />Wazardous substance found in the s��dary containment, - <br />r, <br />Quantity: --*Lbp g concentration: <br />The method and location of disposal of the released hazardous substance: P!�A -/ °f <br />Description of actions taken to repair the UST and to prevent futurb releases. Attach a copy Of the <br />maintenance receipt: —T'T--p VU ®_ 0, <br />Describe how the monitoring system was reactivated after repairs or replacement' <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 />90 39Vd 0 TiN00A invd 690TE66150Z /-5:60 660Z/60/ZT <br />