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s <br /> eel <br /> CIA eA10 r SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME=NT JUL 2 5 2g)2 <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)465-3433 Web.www,s' ov.or /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 Plan. This form may be used to meet the recording requirements* 9 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. ( i /F <br /> AND <br /> 2. The release has not escaped the secondary containment. 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. TO F <br /> If all conditions above are not fulfilled you must re -ort the releas to the San Joaquin County <br /> Environmental Health Department and other agencies as appropriate. Date of release: <br /> Operator's name: ` 7ro __Phone Number: 2Acl 0—; <br /> Facility name: Y r-.- P.r) Facility Address: } . <br /> Hazardous substance found in the secondary containment: <br /> Quantity: - Concentration: <br /> Description�of the act Dni to en to control and clew up the release: <br /> AL <br /> eve <br /> ThA method @no location of dispos I of the released,hazardous substance: - <br /> Description of actions take to repair the�and prevent future releases Attach a copy of the <br /> mai enance receipt: � � <br /> N �. — �. <br /> Describe how the monitoring system was reactivated after repairs or replacement: <br /> Attach printout from continuous monitoring system, maintenance receipts, manifests, photos,W. <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 /> TOOOITOOO Z duoa KSH MOMW %Y3 Rd 6Z:Z ZTOZ/gZ/Lo <br />