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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE LEAK /CONTAMINATION SITE REPORT <br /> EMERGENCY CES REPORT FILED <br /> VES F T NO 1XI YES 1:1 NO <br /> REPORT DATE CASE N 7} gt}f } ICq}j <br /> 01 21 21 01 01 51 05-1172 t? <br /> :. ...... <br /> MMODYY <br /> NAME OF INDIVIDUAL FILLING REPORT PRO <br /> Ian A.Ellis (336)315-2831 <br /> REPRESENTING COMPANY OR AGENCY NAME <br /> REPORTED O LOCAL AGENCY O REGIONAL BOARD <br /> BY Ox OWNEROPERATOR OTHER Giibarco Veeder Root <br /> ADDRESS <br /> 7300 W.Friendly Ave Greensboro NO 27420-2087 <br /> STREET CITY ST ZIP <br /> NAME CONTACT PERSON <br /> Safeway,Inc. James Schwartz 925-469-7306 <br /> RESPONSIBLE <br /> PARTY 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 /> WE <br /> LOCATION 2808 Country Club Blvd Stockton CA 95204 <br /> ADDRESS CITY ST ZIP <br /> CROSS STREET <br /> LOCALAGENCY AGENCYNAME CONTACT PERSON PHONE <br /> AGENCIES County of San Joaquin CUPA Doug Wilson 209-468-3446 <br /> PHONE <br /> OES Swtt Marotte 800-852-7550 <br /> i NAME QUANTITY LOST(GALLONS) <br /> Gasoline <br /> SUBSTANCE 2 gallons Ex <br /> INVOLVED 2 QUANDTY LOST(GALLONS) <br /> 0 UNKNOWN <br /> D 2 2 6 Q $ ❑TANKTEST ❑TANK REMOVAL NUISANCE CONDITIONS <br /> M M D D Y Y ID INVENTORYCONTROL 1:1 SUBSURFACE MONITORING Seen Visually OTHERI71 <br /> METHOD USED TO STOP DISCHARGE <br /> DATE DISCHARGE BEGAN OUNKNOWN O REMOVE CONTENTS CLOSE TANK&FILL IN PLACED <br /> DISCOVERY 01 2 2 0 01 $ 1:1REPAIRTANK <br /> REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED X YES NO <br /> & O REPLACE TANK CHANGE PROCEDURE O <br /> ABATEMENT 01 21 21 01 01 5 CLOSURE TANK&REMOVAL Disabled Dispensing OTHER <br /> SOURCE OF DISCHARGE CAUSE(Si <br /> O TANK TEST UNKNOWN O OVERFILL UNKNOWN Q <br /> O PIPING LEAK OTHER O CORROSION SPILL E] <br /> Dispenser REPTURE:FAILURE Customer Error N <br /> CHECK ONE ONLY <br /> CASE TYPE OTHER Concrete SOIL ONLY GROUNDWATER DRINKING WATER(WELLS AFFECTED) <br /> CHECK ONE ONLY <br /> CURRENT QNO ACTION TAKEN O PRELIMINARY SITE ASSESSMENT SUBMITTED POLLUTION CHARACTERIZATION O <br /> STATUS O LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS Q <br /> O REMEDIATION PLAN ®CASE CLOSED(COMPLE .UNNECESSARY) CLEANUP UNDERWAY <br /> CHECKAFPROPRIATE ACTIONS( <br /> CAP SITE fCDI EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) F <br /> REMEDIAL Q CONTAINMENT BARRIERCB) EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATERGT) <br /> ACTION VACUUM EXTRACT(VE) NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) Q <br /> VENT S014V5) ❑X OTHER See Comments ENHANCED BIO DEGRADATION(IT) E] <br /> Customer overfilled gas can at pump#9&10 causing 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 /> =2005 <br /> 11:08 AM <br />