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• REGE-IvEL. <br />SAN JO <br />nrpA"Acro- <br />1868 <br />relephone: <br />r.) 468-3420 - 468-3433 <br />.. <br />igolljg* 141111 <br />lWil <br />iif <br />aL01 14 rA i <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 rewrding requiremenw 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. C' -T) F <br />AND <br />3. The release does not Increasehazard offire orexplosion. <br />AND <br />3 The release as_ :. i re deterioration a _ s.0 ii ids. #..n ,;... <br />_t •7s". �yti r i t t► �.-=��.. a. r � ..t: i. i <br />Environmental Health Departmentand other agencies as appropriate.Date of <br />J& Phone Number:_ <br />Facility name:rY."-,f'Y Facility t t" - -mow '11 <br />Hazardous substance found in the secondary containment - <br />MEM <br />Concentration:- <br />The method and location of disposal of the released hazardous substance: <br />i { _ _ '' ♦ s: iii i ` - <br />reactivated after repa)rs or replacement: <br />Attach pr€ntout from continuous monitoring system, maintenance receipts, maFmsts. 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, l3tle 23, Section 2851 and California Health & Safety Code Section <br />25294 for further requirements, <br />PO'd VS:Z1 VLOZ 1S Inf 016199b60Z:X83 10d 30 NVA <br />