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SAN JOAQUIMCOUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />6DOEast Main Street, Stockton, CAg52O2-302& <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.o[g/ehd <br />An owner or operator is required to record all releases from the primary containment, as approved in <br />this facility's Response Phan. This form may be used to meet the recording requirements* if all of the <br />conditions below are true. <br />1' The owner oroperator can clean upthe release from the primary containment <br />within 8hours after the release was detected orshould 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 offire orexplosion. F <br />AND <br />4. The release does not cause deterioration ofthe secondary containment. F <br />Ifall conditions above are not fulfilled you must report the release to the San Joaquin County <br />Environmste. Date ofrelease: <br />____ <br />Operator's name-_]<�)�060 �r�VaC�IhPhone Number: <br />Facility name: 46110 Facility Address: <br />72e5�i -2 -� <br />Ca- Olt <br />Hazardous substance found inthe secondary containment: <br />AIMu*4' Concentration: �0 <br />Description ofthe actions taken tocontrol and clean upthe release: <br />The method and location of disposal of the released hazardous substance: �5(-C hn j0 <br />Description of actions taken to repair the UST and to prevent future releases, Attach acopy ofthe ^~" <br />Describe how the monitoring system wjs reactivated after repairs or �~~~ <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 />25284for further requirements. <br />