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UNDERGROUND STORAGE`.rNK UNAUTHORIZED RELEASE LEAK ICL. AMINATION SITE REPORT <br /> EMERGENCY DES RE PORT FI LED Rf1R OCAL AOENCY VSE ONLY <br /> YES NO ❑X YES 1-1 NO (HEREB�`C.1;RriFYTHAFl HAVE OlSTRVBUT6Q THIB INPORmrLUN <br /> REPORT DATE CASEM ACGORD]N[G Tt1 FHE QESrR16LtTK]N SHIkNN GF THE 9FCKF'Ac. •13=.h'd <br /> Of 21 21 61 01 5� 05-1326 <br /> M M D D Y Y � <br /> NAME OF INDIVIDUAL FILLING REPORT PHONE „r <br /> Ian A. Ellis 1 (336)315-2831 <br /> REPRESENTING COMPANY OR AGENCY NOME <br /> REPORTED O LOCA-AGENCY O REGIONAL BOARD <br /> BY OX ONMEMPERATOR OTHER Gilbarco Veeder Root <br /> ADDRESS <br /> 7300 W.Friendly Ave Greensboro NC 27420-2087 <br /> STREET CITY ST ZIP <br /> NAME CONTACT PERSON <br /> RES <br /> Safeway, Inc. James Schwartz 925-469-7306 <br /> PARAK I TrY L ADDRESS <br /> P.O. Box 9070 Pleasanton CA 94588-3229 <br /> STREET CITY ST ZIP <br /> FACILITY NAME OPERATOR PHONE <br /> 1769 Safeway- Nor Cal Sharon Louveture 209461-5555 <br /> SPIE <br /> LOCATION 2808 Country Club Blvd Stockton CA 95204 <br /> ADDRESS CITY ST ZIP <br /> CROSS STREET <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> AGENCIES County of San Joaquin CUPA Doug Wilson 209-468-3446 <br /> PHONE <br /> OES Sybil Clark 800-852-7550 <br /> Gasoline NAME QUANTITY LOST(GALLONS) <br /> SUBSTANCE 2 gallons El <br /> INVOLVED 2 QUANTITY LOTT(GALLONS) <br /> DATEDISCOVEREDUNKNONM <br /> 0 2 2 6 0 5 �TANKTEST TANK REMOVAL NUISANCE CONDITIONS <br /> M M D D Y Y INVENTORY CONTROL rI SUBSURFACE MONITORING Seen Visually -OTHEREJ <br /> METHOD USED TO STOP DISCHARGE <br /> DATE DISCHARGE BEGAN O UNKNCNN REMOVE CONTENTS CLOSE TANK&FILL IN PLACE Q <br /> DISCOVERY 0 2 26 IM <br /> 5 REPAIR TANK REPAIRPIPING <br /> HAS DISCHARGE BEENSTOPPED X YES NO <br /> & REPLACE TANK CHANGE PROCEDURE 0 <br /> ABATEMENT 0 2 2 6 0 5 CLOSURE TANK&REMOVAL Customer vehicle evacuated OTHER® <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> O TANK TEST UNKNONM O 0 OVERFILL UNKNOWN Q <br /> O PIPING LEAK OTHER MX D CORROSION SPILL <br /> Vehicle ❑REPTURE/FAILURE Customer Error <br /> CHECK ONE ONLY <br /> CASE TYPE F-XI OTHER Concrete SOIL ONLY GROUND WATER DRINKING WATER(WELLS AFFECTED) <br /> CHECK ONE ONLY <br /> CURRENT ONO ACTION TAKEN O PRELIMINARY SITE ASSESSMENT SUBMITTED POLLUTION CHARACTERIZATION <br /> STATUS O LEAK BEING CONFIRMED O PRELIMINARY SITE ASSESSMENT UNDERMY POST CLEANUP MONITORING IN PROGRESS 0 <br /> O REMEDIATION PLAN ®CASE CLOSED(COMPLETED/UNNECESSARY) CLEANUP UNDERWAY <br /> CHECKAPPROPRIATE ACTION(S) <br /> CAP SITE(CD) EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) <br /> REMEDIPl O CONTAINMENT BARRIER(CEN EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDYVATER(GT) Q <br /> ACTION O VACUUM EXTRACT(VE) O NO ACTION REQUIRED(NA) TREATMENTAT HOOKUP(HO) <br /> ED VENT SOIL(VS) �X OTHER See Comments ENHANCED BIO DEGRADATIORIT) <br /> A hole in the customers gas tank caused gasoline to reach the concrete pavement. <br /> Station used FM186 and absorbent pads 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 /> 0 <br /> 3i3PM <br />