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0 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 Wreb.* www.s{qov.orq/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 Pian. 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 `'T 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 re 0 5 - Phone Number. ?,-) I <br />Facility Facility Address` '.� <br />Hazardous substance found in the secondary containment: U <br />Quantity: 2- S <br />Concentration: <br />Description of the actions taken to control and clean up the release: <br />Tv«.. l.t a�E3i <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 />mAntenance receipt: <br />Describe how the monitoring system was reactivated after repairs or replacement: <br />P6-c'tom' Fr_ ,,..-r-- <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 />y'p l� -, ,L ow� 6,0, <br />