Laserfiche WebLink
Nov 201211;52a Chris Buscaglia 2099560214 p.4 <br />9 0 0 <br />SAN JOAQUIN COUNTY <br />ENWRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone. (209) 468-3420 Fax. (209) 468-3433 Web.* www, sigoy.onglehd <br />09=91W= I, <br />11*1 Z4111 0 F.11111 I'm 101 V [r4:9 NJ VA IN <br />An owner or operator is required to record aR 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 cleanup the release from the primary containment <br />.mn in F <br />AN'' 'th' 8 hours after the release was detected or should have been detected. <br />2. �he release has not escaped the secondary containment. -'-F, F <br />3. <br />AN � The release does not increase the hazard of fire or explosion. F <br />AN <br />4 qbe 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 appro nate. Date of release:_ 1 14 1 V1- <br />Operator's name: Phone Wtumber: <br />Facility name:S-t3' <br />ALRM Facility Address: -3,� 4- <br />6g� <br />Hazardous substance found in the secondary containment: b4,1 - <br />Quantity: 2. 0-Z Concentration: ?') ra, <br />Description of the actions taken to control and clean up the release: <br />-%--z � I SL --o 0:f 1) g."k P— L-= I T ra. ip , <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: P i ol, C,(,' 332 <br />Describe how the monitoring system was reactivated after repairs or replacement: <br />Sy " <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 />