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EMERGENCY UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE LEAK /CONTAMINATION SITE REPORT <br /> DES REPORT FILED ' <br /> YES Ej NO 1-1 <br /> NO ...... <br /> 1EVES >> ch, ,Y1:4L4T1�®e}TE4 THf3 p9FOR&tF71[�N <br /> REPORT DATE �E R <br /> SHdwAi <br /> 01 91 01 11 01 5105-5118 ;',eve. ,••"` .......... �R' iS' :. <br /> M M D D Y Y •.q4 a.•.:?S::r:�a�,Oky.: <br /> NAME OF INDMDUAL FILLING REPORT <br /> Ian A. Ellis 336315-2837 <br /> REPRESENTING COMPANY OR AGENCY NAME <br /> REPORTED O LOCAL AGENCY O REGIONAL BOARD <br /> BY FX OWNERX)PERATOR OTHER Gllbarco Veeder Root <br /> ADDRESS <br /> 7300 W. Friendly Ave Greensboro NC 27420-2087 <br /> STREET <br /> CITY ST NAME ZIP <br /> CONTACT PERSON <br /> Safeway,Inc. James Schwartz 925-489-7306 <br /> RESPONSIBLE <br /> PARTY ADDRESS <br /> P.O.Box 9070 Pleasanton <br /> STREET CA' 9458 <br /> FACILITY NAME Citt ST zip ZIP <br /> OPERATOR PHONE <br /> 1769 Safeway-Nor Cal Sharon Louveture 209-461-5555 <br /> SITE <br /> LOCATION 2808 Country Club Blvd Stockton CA 95404 <br /> ADDRESS CITY ST ZIP <br /> CROSSSTREET <br /> LOCALAGENCY AGENCYNAME CONTACT PERSON PHONE <br /> AGENCIES County of San Joaquin CUPA Doug Wilson 2094663446 <br /> PHONE <br /> OES Danelle Langford 800.852-7558 <br /> Gasoline NAME pUANTILO—LOST(GALLONS) <br /> SUBSTANCE 3 gallons ❑X <br /> INVOLVED 2 <br /> QUANTITY LOST(GALLONS) <br /> HOW DISCOVERED — 1:1 UNKNOWN <br /> 0 0,911 OVIN <br /> 0 5 F-1TANKTEST TANK REMOVAL NUISANCECONDIT)ONS 11 <br /> M M D D Y Y INVENTORYCONTROL M SUBSURFACE MONITORING Seen Visually OTHER <br /> METHOD USED TO STOP DISCHARGE <br /> DATE DISCHARGE BEGAN OUNKNOWN REMOVE CONTENTS CLOSE TANK&FILL IN PLACE 0 <br /> DISCOVERY 0 9 0 1 0 5 REPAIR TANK REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED X YES NO <br /> & REPLACE TANK CHANGE PROCEDURE O <br /> ABATEMENT 0 9 0 1 0 5 CLOSURE TANK&REMOVAL Customer vehicle evacuated OTHER <br /> SOURCE OF DISCHARGE CAUSES) <br /> O TANK TEST UNKNOWN O O OVERFILL UNKNOWN <br /> O PIPING LEAK OTHER ❑X CORROSION SPILL <br /> Customer Vehicle REPTURE/FAILURE Hole in customer gas tank OTHER <br /> CHECK ONE ONLY <br /> CASE TYPEOTHER Concrete SOIL ONLY GROUNDWATER DRINKING WATER(WELLS AFFECTED) <br /> CHECK ONE ONLY <br /> CURRENT NO ACTION TAKEN O PRELIMINARY SITE ASSESSMENT SUBMITTED POLLUTION CHARACTERIZATION <br /> STATUS O LEAK BEING CONFIRMED O PRELIMINARY SITE ASSESSMENT UNDERWAY 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) El <br /> REMEDIAL O CONTAINMENT BARRIER(CB) O EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) 0 <br /> ACTION OVACUUM EXTRACT(VE) XO NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) <br /> VENT SOIL(VS) ❑OTHER ENHANCED BIO DEGRADATION(IT) El <br /> A hole in customer gas tank caused 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 /> 9/152005 <br /> 1:15 PM <br />