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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE LEAK I CONTAMINATION SITE REPORT <br /> EMERGENCY OES REPORT FILED FOR LOCAL AGEH[_Y USE ONLY '� <br /> YES NO �X YES NO I HERE CERTIFY' HAVEDISTRIBU'IE NFO R TIO <br /> REPORT DATE <br /> GAZE# ACCORDING TO THE I HOWNOFT}1EBAC. PAGE"OF7HIS'FORM_ <br /> 01 21 21 31 11 01 10-1325 <br /> stRleunON s M1_ <br /> M M D DY Y .._ <br /> SIGNED `. . _ .q; E�.- <br /> DAI <br /> NAME OF INDIVIDUAL FILLING REPORT <br /> Jason Patriquin (336)315-2816 <br /> REPRESENTING COMPANY OR AGENCY NAME <br /> REPORTED ED LOCAL AGENCY F-1 REGIONAL BOARD <br /> BY a]OWNER/OPERATOR OTHER Gilbarco Veeder Root <br /> ADDRESS <br /> 7300 W.Friendly Ave Greensboro NC 27420-2087 i <br /> STREET CITY ST ZIP <br /> NAME GONTACTPERSON <br /> i <br /> Safeway-North California Stan Olea 925-467-2707 <br /> RESPONSIBLE <br /> PARTY ADDRESS <br /> 5918 Stoneridge mall rd Bldg 6000,2nd floor <br /> Pleasanton CA 94588 <br /> STREET CITY ST ZIP <br /> FACILITY NAME OPERATOR PHONE <br /> Safeway-IVar Cal MANAGER 209-461-5555 <br /> SITE <br /> LOCATION 2808 Country Club Blvd Stockton CA 95204 <br /> ADDRESS CITY ST ZIP <br /> CROSS STRE - I <br /> I <br /> I <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> AGENCIES SAN JOAQUIN County Stacey 209-468-3446 <br /> PHONE <br /> OES Ron 800-852-7550 <br /> 1 NAME QUANTITY LOST(GALLONS: <br /> Chemical-Antifreeze <br /> SUBSTANCE 2 gallons <br /> l <br /> INVOLVED 2 QUANTITY LOST(GALLONS; <br /> UNKNOWN <br /> 0 <br /> _21 21 2L] <br /> 0 ❑TANK TEST ❑TANK REMOVAL NUISANCE CONDITIONS <br /> M M D D Y Y INVENTORY CONTROL SUBSURFACE MONITORING Seen Visually OTHER <br /> METHOD USED TO STOP DISCHARGE <br /> DATE DISCHARGE BEGAN UNKNOWN REMOVE CONTENTS CLOSE TANK&FILL IN PLACE <br /> I <br /> DISCOVERY 0 21 21 21 11 01 REPAIRTANK REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED X YES NO <br /> 8: �REPLACE TANK CHANGE PROCEDURE <br /> - ABATEMENT 01 21 21 21 11 0 CLOSURE TANK&REMOVAL See Comments OTHER <br /> SOURCE OF DISCHARGE _ CAUSE(S) <br /> TANK TEST UNKNOWN OVERFILL UNKNOWN <br /> PIPING LEAK OTHER CORROSION SPILL <br /> Equipment failure REPTURE/FAILURE Customer's vehicle OTHER �X <br /> CHECK ONE ONLY <br /> CASE TYPE a]OTHER Concrete ❑SOIL ONLY ❑GROUNDWATER DRINKING WATER(WELLS AFFECTED) ❑ <br /> CHECK ONE ONLY <br /> CURRENT =NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT SUBMITTED POLLUTION CHARACTERIZATION <br /> STATUS LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP_MONITORING IN PROGRESS <br /> REMEDIATION PLAN ®CASE CLOSED(COMPLETED/UNNECESSARY) CLEANUP UNDERWAY <br /> CHECKAPPROPRIATE ACTION(S) <br /> CAP SITE(CD) EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) <br /> REMEDIAL CONTAINMENT BARRIER(CB) EXCAVATE&TREAT(Er) PUMP&TREAT GROUNDWATER(Gr) <br /> ACTION 0 VACUUM EXTRACT(VE) NO ACTION REQUIRED(NA) - TREATMENT ATHOOKUP(HU) <br /> VENT SOIL(VS) �X OTHER See Comments ENHANCED BIO DEGRADATION(n) <br /> The spill was due to a customers vehicle leaking anti freeze to concrete only. <br /> As a result 2 gallons of antifreeze impacted the concrete.No fuel impacted the storm drain or soil. <br /> COMMENTS Antifreeze was cleaned up with absorbent pads. - <br /> Safeway-has responded to this issue and all necessary action has-been taken.No further actions are currently planned. <br /> I 2x2=10 <br /> 12:18 PM <br />