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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE LEAK 1 CONTAMINATION SITE REPORT <br /> EMERGENCY _ OES REPPRT FILED - FOR'.L0CAL AGENCY <br /> YES �X - NO ❑X YES _ NO E�HE_RI=BYCER7SFY7gIAT. VEDISTRIBCFTEB.FFiISINFORMATION <br /> REPORT GATE CASE# - .ACCORDING_T0IT1J [$T'i21BtrRONLSii OF'HEBAGK-PAGEOFTNIS-CORM. <br /> 11 01 11 71 01 T08-7442 _ <br /> -- -. . .- - - --- <br /> M M D D Y Y *111 -- -51GNED - L]AiE�flfll� I <br /> NAME OF INDIVIDUAL FILLING REPORT 1 <br /> Brandon Eads <br /> (336).315-2806 <br /> REPRESENTING - COMPANY OR AGENCY NA E i <br /> REPORTED LOCALAGENCY REGIONAL BOARD <br /> BY OWNER/OPERATOR OTHER Gllbarco Veeder Root <br /> ADDRESS <br /> 7300 W. Friendly Ave Greensboro NC 27420-2087 <br /> STREET CITY ST ZIP ! <br /> NAME CONTACT PERSON 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-Nor Cal MANAGER 209-472-8600 x1219 <br /> SITE <br /> LOCATION 6425 N Pacific Stockton CA 95207 <br /> ADDRESS CITY ST ZIP <br /> CROSS STREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> AGENCIES County of SAN JOAQUIN - Pam 209468-3446 <br /> PHONE <br /> OES Dana Peterson 800-852-7550 <br /> 1 NAME QUANTITY LOST(GALLONS: <br /> Gasoline <br /> SUBSTANCE 2 Gallons Ex <br /> INVOLVED 2 QUANT3TYLOST(GALLONS <br /> : <br /> UNKNOWN <br /> URI t7 Ul-�-UVtKtU HIM UIbGUVLRED <br /> 1 0 1 5 0 8 TANK TEST ❑TANK REMOVAL NUISANCE CONDITIONS <br /> M M D D Y Y INVENTORY CONTROL ❑SUBSURFACE MONITORING Seen Visually - OTHER E { <br /> METHOD USED TO STOP DISCHARGE { <br /> DATE DISCHARGE BEGAN UNKNOWN REMOVE CONTENTS CLOSE TANK&FILL IN PLACE <br /> DISCOVERY 11 ol 11 51 0 8 - REPAIR TANK REPAIR PIPING ❑ <br /> HAS DISCHARGE BEEN STOPPED X YES Li NO <br /> & . REPLACE TANK CHANGE PROCEDURE- <br /> ABATEMENT <br /> ROCEDUREABATEMENT 11 0 11 51 01 8 CLOSURE TANK&REMOVAL FM 186 and absorbent pads OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> TANK TEST UNKNOWN F-1 F-1 OVERFILL UNKNOWN _ <br /> PIPING LEAK OTHER CORROSION SPILL E] <br /> Dispenser ❑REPTURE 7 FAILURE Customer Error OTHER <br /> CHECK ONE ONLY <br /> CASE TYPE M OTHER concrete SOIL ONLY GROUND WATER 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 1 UNNECESSARY) CLEANUP UNDERWAY <br /> CHECKAPPROPRIATE ACTION(S) <br /> FICAP SITE(CD) F--1 EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) ❑ <br /> REMEDIAL =CONTAINMENT BARRIER(CB) EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(G-0 <br /> ACTION VACUUM EXTRACT(VE) NO ACTION REQU I RED(NA) TREATMENT AT HOOKUP(HU) <br /> VENT SOIL(VS) �X._ OTHER See Comments ENHANCED BIO DEGRADATION(IT) ❑ <br /> Per Julia at site,a customer pulled the hose to the apposite side of the car to dispense and the nozzle fell out of the gas tank. <br /> As a result 2 gallons of fuel spilled onto the concrete surface. <br /> COMMENTS No fuel impacted the storm drain or soil. - <br /> Fuel was cleaned up with spill kit(fm 186 hydro carbon cleaner agent). <br /> Safeway has responded to this issue and all necessary action has been taken.No further actions are currently planned. <br /> E 1 019 71200 8 <br /> 4'45 PM <br />