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UNDERGROUND STORA22�RhNK UNAUTHORIZED RELEASE(LEAKI/CisgotAMINATION SITE REPORT <br /> EMERGENCYOES REPORT FILED 6f1R L�Gtt ABENCYTIS „y' .'. <br /> YES NO ❑X YES NO AWRt6Y GEli71PY7HAT1}L.........1�1&TR10ti....—,US3.... 1tElQN <br /> REPORT DOTE CASE# BfRD]NG TAIHET1E51R10UYIQN3}IOwQFt(7FY+1R6AC&PASiE'OFJHIS FARKt. <br /> 01 21 21 71 01 5 05-1335 <br /> M M D D Y V .AIC�tA64 " DATE <br /> NAME OF INDIVIDUAL FILLING REPORT <br /> F:a <br /> Ian A. Ellis (336)315-2831 01--� <br /> REPRESENTING COMPANY OR AGENCY NAME <br /> REPORTED O LOCALAGENCY Q REGIONAL BOARD <br /> BY F--1 CWNER,VPERATOR OTHER Gllbarco Veeder Root <br /> ADDRESS <br /> 7300 W.Friendly Ave Greensboro NC 27420-2087 <br /> STREET CITY ST ZIP <br /> NAME CONTACT PERSON <br /> RESPONSIBLE <br /> Safeway,Inc. James Schwartz 925469-7306 <br /> PARTY <br /> 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 209-461-5555 <br /> EII,E., 2808 Country Club Blvd Stockton CA 95204 <br /> ADDRESS CITY ST ZIP <br /> CROSS STREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> AGENCIES County of San Joaquin CUPA Doug Wilson 209-468-3446 <br /> PHONE <br /> OES Kevin 800-852-7550 <br /> NAME QUANTITY LOST(GALLONS) <br /> Gasoline <br /> SUBSTANCE 1 gallon <br /> INVOLVED P QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> 0 2 2 7 0 5 �TANKTEST TANK REMOVAL NUISANCECONCITIONS <br /> M M D D Y Y INVENTORY CONTROL SUBSURFACE MONITORING Seen Visually OTHER X� <br /> METHOD USED TO STOP DISCHARGE <br /> DATE DISCHARGE BEGAN OUNKNOWN QREMOVE CONTENTS CLOSE TANK B FILL IN PLACEQ <br /> DISCOVERY 0 21 21 71 01 5 REPAIR TANK REPAIR PIPING <br /> HAS DISCHARGE0 BEEN STOPPED % YES NO <br /> & REPLACE TANK CHANGE PROCEDURE 0 <br /> ABATEMENT 0 2 2 7 0 5 CLOSURE TANK&REMOVAL Dispenser disabled OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> O TANK TEST UNKNOWN Q Q OVERFILL UNKNOWN Q <br /> O PIPING LEAK OTHER ❑% F-1 CORROSION SPILL <br /> Dispenser REPTURE I FAILURE Auto shut off failed FX <br /> CHECK ONE ONLY <br /> CASE TYPE EX OTHER Concrete SOIL ONLY GROUNDWATER DRINKING WATER(WELLS AFFECTED) <br /> CHECK ONE ONLYCURRENT r-1 W PRELIMINARY <br /> ION TAKEN r7 <br /> SANS O LEAK BENG CONFIRMED Q PRELIMINARY SITE ASSESSMENTUNDERWAY POST CLEANUP MONITORINGIN PROGRESS <br /> 0 <br /> ONEMEDIATION PLAN ®CASE CLOSED(COMPLETED I UNNECESSARY) CLEANUP UNDERWAY E] <br /> CHECKAPPROPRIATE ACTIONS) <br /> =CAP SITE(ED) �EXCAVATE&DISPOSE(ED) REMOVE FREE PROWCT(FP) <br /> REMEDIAL O CONTAINMENT SARRIER(CS) Q EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) <br /> Q <br /> ACTION O VACUUM EXTRACT(VE) O NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) <br /> VENT SOIL(VS) OTHER See Comments ENHANCED BIO DEGRADATIOMIT) <br /> Auto shutoff failed on pump#7 caused gasoline to reach 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 /> 3/32005 <br /> 3:Q PM <br />