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SAN JOAQUIN COUNTY fb <br />OVIRONMENTAL HEALTH DEPARTMENT <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 <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. 0 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: C � one Number: t2� % :y �( <br />Facility name: v Pacility Address: ��25 w' •1-0`( a+4 <br />-A L r a.i,u✓ %1a -+dl: <br />Hazardous substance found in the secondary containment: <br />Quantity: Concentration: O -I <br />Description of the actions taken to control and clean up the releaseC 14 IK P <br />- <br />The method and location of disposal of the released hazardous substance: P4'''� �% Ia`j <br />�� f'— <br />Description <br />Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the <br />maintenance receipt: <br />b <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 />