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i <br /> SAN JOAQUIN COUNTY I <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E . Hazelton Ave . , Stockton , CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web : www . sigov . or /q 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* 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 . 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 . 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 : 9 - .3 <br /> Operator' s name : & 1fulgs if S �Iv614 Phone Number: SID -S"� X 1/5 c)g <br /> Facility name : P /N v m ry 7 Facility Address : 00 / R +•� os � rH, r � � '"'¢^"-� �� <br /> Hazardous substance found in the secondary containment : hirscc. STe Sure-' <br /> Quantity : /9 j9geo . L10064 ,L5 Concentration : l 0 0 70 <br /> Description of the actions taken to control and clean up the release : <br /> The method and location of disposal of the released hazardous substance : 6EL %t %jE1eb <br /> �'o.� .4i�/ t,1 TO(7 /C T15�E Pi2Ud ucr'/3w9�s <br /> Description of actions taken to repair the UST and to prevent future releases . Attach a copy of the <br /> maintenance receipt : r0 � �,o � ,�es oZEc� �; zi �� �� ,7,�,sx.,� c, A -Ssvr� <br /> U S TT¢ silz.E wou LA ry cs M <br /> Describe how the monitoring system was reactivated after repairs or replacement : <br /> .Svr� l� /3 � ✓3n.rnC.t.FJ¢2�� rt �c�� i�iZo,puc.T �.c>/45sZEr+� yU.� <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 />