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UNDERGROUND STORAGE TANK <br /> EAiERG Y UNAUTHORIZED RELEASE LEAK /CONTAMINATION SITE REPORT <br /> ❑ <br /> YES F. CES❑REP'YES <br /> FILEL❑ NC <br /> ^K <br /> REPORT DATE CASE ti <br /> --20L..61 11 61 0l 51 05-3624 <br /> M M D D Y <br /> NAME OF INDIVIDUAL FI W NG REPORT <br /> Ian A.Ellis 336-315-2837 OL_ (+ <br /> REPRESENTING COMPANY RAGENCY NAME <br /> REPORTED O LOCAL AGENCY REGIONAL BOARD <br /> BY a OWNER!OPERATOR o OTHER Ciibarco Veeder Root <br /> ADDRESS <br /> 7300 W.Friendly Ave Greensboro NO 27420-2087 <br /> STREET CITY <br /> ST <br /> NAME CONTACT PERSON <br /> RESPONSIBLE 21P <br /> Safeway, Inc. James Schwartz 925-469-7306 <br /> PARTY ADDRESS <br /> P.O.Box 9070 Pleasanton CA 94588-3229 <br /> STREET CITY ST Zip <br /> FACILITY NAME OPERATOR <br /> PHONE_ <br /> 7769 Safeway-Nor Cal Sharon Louveture 209461-5555 <br /> SITE <br /> LOCATION 2808 Country Club Blvd Stockton CA 95204 <br /> ADDRESS CITY Sr LIP <br /> CROSS STREET <br /> LOCAL AGENCY AGENCY NAME CONTACTPERSONPHONE <br /> AGENCIES County of San Joaquin CUPA Doug`Nilson 209-468-3446 <br /> PHONE <br /> DES Randy Gonzalez 800-852-7550 <br /> I NAME OUAWITVLOST(GALLONS) <br /> Gasoline <br /> SUBSTANCE 112 gallon El <br /> INVOLVED e -OUAW Try LOST IGAll NS) <br /> 0 UNKNOWN <br /> HOW UIET�UVLHLU <br /> 0 61 11 6 01 5 F-1 TANK TEST TANK REMOVAL NUISANCECONDITIONS <br /> M M D D Y Y o INVENTORY CONTROL SUBSURFACE MONITORING Seen Visually OTHER x� <br /> METHOD USED TO STOP DISCHARGE <br /> DATE DISCHARGE BEGAN OUNKNOWN O REMOVE CONTENTS CLOSE TANK&FILL IN PLACE <br /> DISCOVERY Q 61 16 0 $ FRE..PAIR TANK REPAIRPIPING <br /> HAS DISCHARGE BEEN STOPPED X YES NC <br /> S 0 REPLACE TANK CHANGE PROCEDURE <br /> ABATEMENT 0 6 1 6 0 5 CLOSURE TANK&REMOVAL Dispenser disabled OTHER <br /> SOURCE OF DISCHARGE CAUSEISi <br /> O TANK TEST UNKNOWN <br /> QOVERFILL UNKNOWN <br /> O PIPING LEVO OTHER ❑X EI CORROSION SPILL <br /> Dispenser ❑REPIURE'FAILURE Nozzle leaking OTHER <br /> CHECK ONE ONLY <br /> CASETYPE OTHER Concrete SOIL ONLY GROUNDWATER DRINKING WATER(WELLS AFFFCTEDi <br /> CHECK ONE ONLY <br /> CURRENT QNO ACTION TAKEN O PRELIMINARY SITE ASSESSMENT SUBMITTED POLLUTION CHARACTERZATION O <br /> STATUS Q LEN(BEING CONFIRMED Q PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS 0 <br /> O REMEDIATION RAN ®CASE CLOSED(COMPL.ETED;UNNECESSARY) CLEANUP UNDERWAY <br /> HEI. ;'ROPRIATE AC TION(S) <br /> a CAP SITE CD) EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP;. <br /> REMEDIAL O CONTAINMENT BARRIEROB) OEXCAVATE&TREAT(ET) PUMP B TREAT GROUNDWATERIGT) Q <br /> ACTION OVACUUM EXTRACT WEFX7 NO ACTION REOUIRESINA) TREATMENT AT HOOKU%HU) O <br /> ❑VENT SOIL(VS1 O OTHER ENHANCED BIO DEGRADAT)ON(ITl ❑ <br /> Nozzle is king on pump#1 caused gasoline to reach concrete pavement. <br /> Station used absorbent material to clean the spill. <br /> coMMENrS Safeway has responded to this issue and all necessary action has been taken. <br /> No further actions are currently planned. <br /> 6232005 <br /> 1:21 PM <br />