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0 SAN JOAQUIN COUNTY 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029' <br />468-3420 Fax: 209 468-3433 Web: www.s' ov.or /eh <br />Telephone: (209)( ) ).g g <br />C`��"/VSZ <br />RECORDING REQUIREMENTS Juiv I 12013 <br />FOR UNAUTHORIZED RELEASES <br />An owner or operator is required to record all releases from the primary containment, as as <br />this facility's Response Plan. This form may be used to meet the recording requirements* gallrt <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. V F <br />AND <br />3. The release does not increase the hazard of fire or explosion. 1 F <br />AND <br />4. The release does not cause deterioration of the secondary containment. T 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: c6-- 1(-2_e13 <br />Operator's name: NI !/1 S 11-44 y Phone Number: �ZoCl - 3 33- 12 �d <br />Facility name: � �' ;o Gt,, l:y 9-o Facility Address: 2 S &I_S / /`1.P L-2 � � J <br />/�c /� __1 <br />Hazardous substance found in the secondary containment: D/k S (, e - <br />Quantity: C.UL,,4L l: 0 t-tyc i=S Concentration: �- <br />Description of the actions taken to control and clean up the release: y� <br />The method and location of disposal of the released hazardous substance: <br />i c" 4,0t LL //-j"�5 PZI7 ei <br />Description of actions taken to repair the UST and to prevent future releases. Attach a copy of the <br />maintenance receipt: =LU j / G 1, i H i 3 P- <br />Describe how the monitoring system was reactivated after repairs or replacement: _ <br />/ALL F -`�(u i / 0,-q -S �0 A- •ti. / 0!!L -(r 10/1 i �: ,�C, i.,,5 d'/1 � i.- L_ <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 />