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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.or /g ehd An owner or operator is required to record all releases from the primary containment, as approved in this facility's Response Plan. This form may be used to meet the recording requirements* if all of the conditions below are true. 1. The owner or operator can clean up the release from the primary containment CT,-" within 8 hours after the release was detected or should have been detected. F AND 2. The release has not escaped the secondary containment. T F AND F 3. The release does not increase the hazard of fire or explosion. AND 4. The release does not cause deterioration of the secondary containment. F If all conditions above are not fulfilled you must report the release to the San Joaquin County Environmental Health Department and other agencies as appropriate. A - Date of release: Operator's name: p4 ;� �� Phone Number: cDQ W��' L" L15 ii � C 4. � t Facility name: u ��.�� t7 lJ� Facility Address: Hazardous substance found in the secondary containment: Quantity: (3-tWI-d '� c ��'�4 Concentration: of the actions taken to control and clean up the release: The method and location of disposal of the released hazardous substance: Ag d 91"a Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the maintenance receipt: "S. �V\ � W \n 5 Q, 40M -w,21D-9 jILW 04i\�6 v \-\,Nk�LMCO(Y\Q- com vgvv\i5� Describe how the monitoring system was reactivated after repairs or replacement: Attach printout from continuous monitoring system, maintenance receipts, manifests, photos, etc. Retain this document with your monitoring records for review during the annual inspection by our department. *See the California Code of Regulations, Title 23, Section 2651 and California Health & Safety Code Section 25294 for further requirements.