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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE LEAK / CONTAMINATION SITE REPORT <br /> EMERGENCY OES REPORT FILED LtlCA:!(A6ENCY NLY <br /> *#d�t899`c`E7YF1kY�HR'A� RVE$)h <br /> F1 YES El NO YES NO TRBtREA T.HfS tMFORMATI�N <br /> REPORT DATE CASE AGGDTffi4K3YTSIYS@f}i$>7L`eUFICPt SHCAWM C3FTHE@ACKY0.2DFFYpSFDFWt <br /> of e1 21 71 01 s� 05-5028 <br /> M M D D Y Y 9dDN # <br /> NAME OF INDIVIDUAL FILLING REPORT <br /> Ian A. Ellis 336-315-2837 <br /> REPRESENTING COMPANY OR AGENCY NAME <br /> REPORTED O LOCALAGENCY O REGIONAL BOARD <br /> BY El CWNFRAJPERATOR 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 /> 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 /> SITE <br /> LOCATION 2608 Country Club Blvd Stockton CA 95204 <br /> ADDRESS CITY ST ZIP <br /> CROSSSTREET <br /> LOCALAGENCY AGENCYNAME 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 /> NAME <br /> QUANTITY LOST(GALLONS) <br /> Gasoline <br /> SUBSTANCE 3 gallons El <br /> INVOLVED 2 <br /> QUANTITY LOST(GALLONS) <br /> O UNKNOWN <br /> HOW uISCCVtKtu <br /> 01 8011 21 71 0 5 F-1TANKTEST E]TANKREMOVAL NUISANCE CONDITIONS <br /> M M D D Y Y D INVENTORYCONTROL SUBSURFACE MONITORING Seen Visually OTHER X❑ <br /> METHOD USED TO STOP DISCHARGE <br /> DATE DISCHARGE BEGAN O UNKNOWN O REMOVE CONTENTS CLOSE TANK&FILL IN PEACE <br /> DISCOVERY 0 81 21 71 0 5 REPAIR TANK REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED X YES NO <br /> & Q REPLACE TPNK CHANGE PROCEDURE O <br /> ABATEMENT0 8 2 7 0 5 CLOSURE TANK&REMOVAL Dispenser disabled OTHER© <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> TANK <br /> PING LUNKNOWN <br /> SER ❑% OVERFILL C CORROSION UNKNOWNIL O❑ <br /> Dispenser REPTURE/FAILURE Auto noZ le shut off fail OTHER <br /> CHECK ONE ONLY <br /> CASE TYPE 171 OTHER Concrete EISOILONLY El GROUNDWATER DRINKING WATER(WELLS AFFECTED) <br /> CHECK ONE ONLY <br /> CURRENT NO ACTION TAKEN O PRELIMINARY SITEASSESSMENT SUBMITTED POLLUTION CHARACTERIZATION O <br /> STATUS O LEAK BEING CONFIRMED O PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS ED <br /> O REMEDIATION PLAN ®CASE CLOSED(COMPLETED/UNNECESSARY) CLEANUP UNDERWAY <br /> CHECKAPPROPRIATE ACTION(S) <br /> r7 CAP SITE(CD) ❑EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) <br /> REMEDUIL Q CONTAINMENT aARRIER(CB) Q EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATERIGT) Q <br /> ACTION O VACUUM EXTRACT(VE) Q NO ACTIONREOUIRED(NA) TREATMENT AT HOOKUP(HU) 0 <br /> VENT SOIDVS) El OTHER ENHANCED 810 DEGRADATION(IT) <br /> Auto nozzle shut off fail on pump#6 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 /> I s�rza <br /> 114 PM <br />