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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE LEAK /CONTAMINATION SITE REPORT <br /> EMERGENCY OES REPORT FLED <br /> YES % NO 1E YES 0 NO <br /> REPORT DATE CASE 4 <br /> 01 51 11 21 01 5� May-31 <br /> M M D D Y Y <br /> NAME OF INDIVIDUAL F[WNG REPORT <br /> I 336-375-2837 <br /> Ian A.Ellis �— <br /> REPRESEWING f.OMPANY GR AGENCY NAM <br /> REPORTED O LOCAL AGENCY O REGIONAL BOARD <br /> BY Fx�OWNERIOPERATOR O OTHER Gilbarco Veeder Rom <br /> ADDRESS <br /> 7300 W.Friendly Ave Greensboro NC 27420-2087 <br /> STREET CITY ST ZIP <br /> NAME COWT T PERSON <br /> Safeway,Inc. James Schwartz 925-469-7306 <br /> RESPONSIBLE <br /> PARTY ADDRESS <br /> P.O.Boz 9070 Pleasanton CA 94588-3229 <br /> ZIP <br /> STREET CIN ST 2!P <br /> FACILITY NAME _ OPERATOR Pt10NF. <br /> 1769 Safeway-Nor Cal Sharon Louveture 209-461-5555 <br /> SITE <br /> LOCATION 2808 Country Club Blvd Stockton CA 95204 <br /> ADDRESS CITY Sr ZIP <br /> CROSS STREET <br /> '_OCAL AGENCY AGENCY NAME CONI PERSON PHONE <br /> AGENCIES County of San Joaquin CUPA Doug Wilson 209-468-3446 <br /> PHONE <br /> OES Bob McRae 800-852-7550 <br /> 1 NAME OI ANTITY LOST(GALLONS) <br /> Gasoline <br /> SUBSTANCE 1.5 gallons ❑k <br /> INVOLVED QUANTITY LOST iGALLONSI <br /> UNKNOWN <br /> O S t 2 O 5 <br /> F-1 El❑'IANKREMOVAL NUISANCECONDITIONS <br /> M M D D Y Y Li INVENTORY CONTROL SUBSURFACE MONITORING Seen Visually OTHER <br /> MET HOD USED TO STOP DISCHARGE <br /> DATE DISCHARGE BEGAN QUNKNOWN O REMOVE CONTENTS CLOSE TANK&FILL IN PLACEQ <br /> DISCOVERY 01 51 11 21 01 5 REPAIR TANK REPAMPIPING <br /> HAS DISCHARGE BEEN STOPPED X YES NO g O REPLACE TANK CHANGE PROCEDURE Q <br /> ABATEMENT __2L_5L_11_21 01 51 CLOSURE TANK&REMOVAL Dispenser disabled OTHER® <br /> SOURCE CF DISCHARGE CAUSES) <br /> TANK TEST UNKNOWN O OOVERFILL UNKNOWN O <br /> O PIPING LEAK OTHER ❑X Q CORROSION SPILL <br /> Dispenser REPTUREi FAILURE drive off OTHER ❑% <br /> CHECK ONE ONLY <br /> 7-71 CASE TYPE OTHER Concrete SOIL ONLY El GROUNDWATER DRINKING WATER(WELLS AFFECTED) <br /> CHECK ONE ONLY <br /> CURRENT Q NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT SUBMITTED POLLUTION CHARACTERIZATION O <br /> STATUS Q LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS O <br /> REMEDIATION PLAN ®CASE CLOSED iCOMPLE IrD UNNECESSARY) CLEANUP UNDERWAY El <br /> CHECk&PlpRQPRIATE AD TIONS) <br /> =CAPSITEICD% EXCAVATE&DISPOSE(ED: REMOVE FREE PRODUCT(FP) El <br /> REMEDIAL O CONTAINMENT RARRIERGS) EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) <br /> ACTION O VACUUM EXTRACT NE: Q NO ACTION REQUIRED(NA) TREATMENT AT HOOKURHU) O <br /> a VENT SOILiVSI �O'rHER See Comments ENHANCED BIO DEGRADMtokiI Ti <br /> El <br /> Customer drove off on pumpd5 causing gasoline to reach concrete pavement. <br /> Station used absorbent material to clean the spill. <br /> COMMENTS Safeway has responded to this issue and all necessary action has been taken. <br /> No further actions are currently planned. <br /> 51123,2005 <br /> 5:21 AM <br />