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UNDERGROUND STORAG— WANK UNAUTHORIZED RELEASE (LEAK,. ;ONTAMINATION SITE REPORT <br />LMWNULNCY <br />YES <br />EX <br />OES REPORT FILED <br />FOR LOCAL AGENCY USE ONLY <br />NO <br />❑X YES ❑ NO <br />I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION <br />ACCORDING TO THE DISTRIBUTION SHOWN OF THE BACK PAGE OFTHIS FORM. <br />REPORT DATE <br />CASE # <br />01 31 31 11 11 01 <br />10-2060 <br />M M D <br />D Y Y <br />SIGNED <br />DATE <br />NAME OF INDIVIDUAL FILLING REPORT <br />Brandon Eads <br />(336) 315-2806 <br />REPRESENTING <br />COMPANY OR AGENCY NAME <br />REPORTED <br />= LOCALAGENCY <br />REGIONAL BOARD <br />BY <br />F OWNER/OPERATOR <br />OTHER <br />Gilbarco Veeder Root <br />ADDRESS <br />7300 W. Friendly Ave Greensboro <br />NC 27420-2087 <br />STREET <br />CITY <br />ST ZIP <br />NAME <br />CONTACT PERSON <br />Safeway- North <br />California <br />Stan Olea <br />F925-467-2707 <br />RESPONSIBLE <br />PARTY <br />ADDRESS <br />5918 Stoneridge mall rd Bldg 6000, <br />2nd floor <br />Pleasanton <br />CA 94588 <br />STREET <br />CITY <br />ST ZIP <br />FACILITY NAME <br />OPERATOR <br />PHONE <br />Safeway - Nor Cal <br />MANAGER <br />209-830-2950 x1219 <br />SITE <br />LOCATION <br />1804 W 11th St <br />Tracy <br />CA 95376 <br />ADDRESS <br />CITY <br />ST ZIP <br />CROSS STREET <br />LOCAL AGENCY <br />AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />AGENCIES <br />SAN JOAQUIN County <br />no answer <br />209-468-3446 <br />PHONE <br />OES <br />Bob McRae <br />916-262-1621 <br />1 <br />NAME <br />QUANTITY LOST (GALLONS <br />Gasoline <br />SUBSTANCE <br />2 gallons EX <br />INVOLVED <br />2 <br />QUANTITY LOST (GALLONS: <br />UNKNOWN <br />01 31 21 81 10 <br />FITANK TEST TANK REMOVAL <br />NUISANCE CONDITIONS <br />Ej INVENTORY CONTROL 1:1SUBSURFACE MONITORING <br />Seen Visually OTHER E] <br />M M D D Y Y <br />METHOD USED TO STOP DISCHARGE <br />DATE DISCHARGE BEGAN <br />UNKNOWN <br />E:] REMOVE CONTENTS <br />CLOSE TANK & FILL IN PLACE <br />DISCOVERY <br />01 3 21 $ 1 0 <br />❑ REPAIR TANK <br />REPAIR PIPING ❑ <br />HAS DISCHARGE BEEN STOPPED <br />X YES NO <br />& <br />E] REPLACE TANK <br />CHANGE PROCEDURE <br />ABATEMENT <br />01 31 21 8 11 O <br />Ll CLOSURE TANK & REMOVAL <br />FM -186 OTHER <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />TANK TEST <br />UNKNOWN E <br />OVERFILL <br />UNKNOWN <br />PIPING LEAK <br />OTHER ❑X <br />CORROSION <br />SPILL <br />hose <br />REPTURE / FAILURE <br />hose detached OTHER ❑X <br />CASE TYPE <br />CHECK ONE ONLY <br />MX OTHER concrete <br />❑SOIL ONLY ❑ GROUND WATER <br />DRINKING WATER (WELLS AFFECTED) ❑ <br />CHECK ONE ONLY <br />CURRENT <br />NO ACTION TAKEN <br />PRELIMINARY SITE ASSESSMENT SUBMITTED <br />POLLUTION CHARACTERIZATION Q <br />STATUS <br />LEAK BEING CONFIRMED <br />PRELIMINARY SITE ASSESSMENT UNDERWAY <br />POST CLEANUP MONITORING IN PROGRESS E] <br />REMEDIATION PLAN <br />® CASE CLOSED (COMPLETED / UNNECESSARY) <br />CLEANUP UNDERWAY <br />CHECKAPPROPRIATE ACTION(S) <br />CAP SITE (CD) <br />F-1 EXCAVATE & DISPOSE(ED) <br />REMOVE FREE PRODUCT(FP) <br />REMEDIAL <br />CONTAINMENT BARRIER(CB) <br />EXCAVATE & TREAT(ET) <br />PUMP & TREAT GROUNDWATER(GT) <br />ACTION <br />VACUUM EXTRACT (VE) <br />NO ACTION REQUIRED(NA) <br />TREATMENT AT HOOKUP(HU) E] <br />VENT SOIL(VS) <br />�X OTHER See Comments <br />ENHANCED BIO DEGRADATION(n) ❑ <br />A customer was dispensing on pump #3 regular and the hose detached from top of the pump releasing 2 gallons of fuel on the ground. <br />Fuel was cleaned up with spill kit (FM 186 hydro carbon cleaner agent) and absorbent pads. <br />COMMENTS <br />Safeway has responded to this issue and all necessary action has been taken. No further actions are currently planned. <br />3/31/2010 <br />4:49 PM <br />