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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE LEAK / CONTAMINATION SITE REPORT <br /> EMERGENCY DES REPORT FILED FOR LOCAL AGENCY USE ONLY <br /> DYES a] NO ff] YES Ej NO I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION <br /> REPORT DATE CASE# ACCORDING TO THE DISTRIBUTION SHOWN OF THE BACK PAGE OFTwS FORM. <br /> 11 01 01 41 01 6� 06-5932 <br /> M M 0 D Y Y SIGNED DATE <br /> NAME OF INDIVIDUAL FILLING REPORT - <br /> Corey McMillan 336-315-2837 <br /> REPRESENTINGCOMPANY OR AGENCY N&Ohll <br /> REPORTED O LOCAL AGENCY O REGIONAL BOARD <br /> BY OWNER/OPERATOR O OTHER Gilberto Veeder Rool <br /> ADDRESS <br /> 7300 W.Friendly Ave Greensboro INC 27420-2087 <br /> STREET CITY ST ZIP <br /> NAME CONTACT PERSON <br /> Safeway, Inc. James Schwartz 925469-7306 <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 /> SITE <br /> LOCATION 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 Toni Walthour 800-852-7550 <br /> 1 NAME OUANTITY LOST(GALLONS) <br /> Gasoline <br /> SUBSTANCE 3 gallons El <br /> INVOLVED 2 QUANTITY LUST(GALLONS) <br /> UNKNOWN <br /> 1 01 <br /> 0 1 75LO L6T �TANKTEST TANK REMOVAL NUISANCE CONDITIONS <br /> M M D D Y Y INVENTORY CONTROL SUBSURFACE MONITORING Seen Visually El <br /> METHOD USED TO STOP DISCHARGE <br /> DATE DISCHARGE BEGAN QUNKNOWN O REMOVE CONTENTS CLOSE TANK S FILL IN PLACE <br /> DISCOVERY 1 01 01 $ 01 6 REPAIR TANK REPAIR PIPING E] <br /> HAS DISCHARGE BEEN STOPPED X YES NO <br /> 8 O REPLACETANK CHANGE PROCEDURE O <br /> ABATEMENT 1 O O $ 0 6 CLOSURE TANK&REMOVAL Customer Vehicle evacuated OTHER <br /> SOURCE OF DISCHARGE CAUSES) <br /> O TANK TEST UNKNOWN O OOVERFILL UNKNOWN O <br /> O PIPING LEAK OTHER ❑X CORROSION SPILL <br /> Customer vehicle El REPTUREI FAILURE A hole hol�gaA tank OTHER <br /> CHECK ONE ONLY <br /> CASE TYPE EEOTHER Concrete �SOILONLY GROUNDWATER DRINKING WATER(WELLS AFFECTED) <br /> CHECK ONE ONLY <br /> CURRENT QNO ACTION TAKEN Q PRELIMINARY SITE ASSESSMENT SUBMITTED POLLUTION CHARACTERIZATION O <br /> STATUS LEAK BEING CONFIRMED O PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS Q <br /> REMEDIATION PLAN ®CASE CLOSED(COMPLETED I UNNECESSARY) CLEANUP UNDERWAY <br /> CHECKAPPROPRIATE ACTION(S) <br /> =CAP SITE(CD) F-1 EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) <br /> REMEDIAL O CONTAINMENT BARRIER(CB) O EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GID O <br /> ACTION O VACUUM EXTRACT(VE) O NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) O <br /> ❑VENT SOIL(VS) ❑OTHER ENHANCED BIO DEGRADATIONBT) ❑ <br /> A hole in customer's gas tank caused gasoline to reach concrete surface. <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 /> 1011212006 <br /> 3:39 PM <br />