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UNDERGROUND STORAGE .,,NK UNAUTHORIZED RELEASE LEAK /CL-(AMINATION SITE REPORT <br /> EMERGENCY OES REPORT FILED FQfRLQEAL>4G&pCYUSEONLY '?':: <br /> .< <br /> YESEl NO �X YES El NO tr1 bYGEE;7IFY fffA#tNAVEt]IST#tiBUT E tI$1tVE''tp..A1..... <br /> REPORT DATE CASE# AGCORD)NOTQ3 D457 .....t7K7p;S]iQYt(p:QE:SHE'l3AQKPA'C3$OFimsFORM, <br /> 11 11 21 41 01 4I 04-6143 <br /> M M D D Y Y :i S{G1`f6p - .... .::::. : : <br /> .. .. :.DATE: <br /> NAME OF INDIVIDUAL FILLING REPORT PHONE �iIUNAI <br /> Ian A. Ellis 1(336)315-2831 <br /> REPRESENTING COMPANY OR AGENCY NAME <br /> REPORTED =LOCAL AGENCY REGIONAL BOARD <br /> BY EX OWNER/OPERATOR OTHER Gilbarco Veeder Root <br /> ADDRESS <br /> 7300 W.Friendly Ave Greensboro NC 27420-2087 <br /> STREET CITY ST ZIP <br /> NAME CONTACT PERSON <br /> Safeway-Nor Cal James Schwartz 925-469-7306 <br /> RESPONSIBLE <br /> PARTY ADDRESS <br /> P.O BOX 9070 Building 6000 Pleasanton CA 94588 <br /> STREET CITY ST ZIP <br /> FACILITY NAME OPERATOR PHONE <br /> 2600 Safeway-Nor Cal Katrina Johnson 209-830-2950 <br /> SITE <br /> LOCATION 1804 W 11th St Tracy CA 95376 <br /> ADDRESS CITY ST ZIP <br /> CROSS STREET <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> AGENCIES County of San Joaquin COPA Doug Wilson 209-468-3446 <br /> PHONE <br /> OES Bob Mcrae 800-852-7550 <br /> 1 NAME QUANTITY LOST(GALLONS) <br /> Gasoline <br /> SUBSTANCE 1 gallon �x <br /> INVOLVED 2 QUANTITY LOST(GALLONS) <br /> ElUNKNOWN <br /> DISCOVEREDDATE O IS O <br /> 1 1 2 4 0 4 F]TANK TEST TANK REMOVAL NUISANCE CONDITIONS <br /> M M D D Y Y El INVENTORY CONTROL [j SUBSURFACE MONITORING Seen Visually OTHER X❑ <br /> METHOD USED TO STOP DISCHARGE <br /> DATE DISCHARGE BEGAN UNKNOWN REMOVE CONTENTS CLOSE TANK&FILL IN PLACE <br /> DISCOVERY 1 1 2 4 0 4 REPAIR TANK REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED X I YES NO <br /> & REPLACE TANK CHANGE PROCEDURE <br /> ABATEMENT 11 11 21 41 01 4 EICLOSURE TANK&REMOVAL dispenser turned off OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> O TANK TEST UNKNOWN [::]OVERFILL UNKNOWN 0 <br /> PIPING LEAK OTHER �X E]CORROSION SPILL ❑ <br /> Dispenser ❑REPTURE/FAILURE Auto shut off failed ❑x <br /> CHECK ONE ONLY <br /> CASE TYPE MX 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 E] <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(ET) PUMP&TREAT GROUNDWATER(GT) <br /> ACTION VACUUM EXTRACT(VE) NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) a <br /> VENT SOIL(VS) ❑X OTHER See Comments ENHANCED BIO DEGRADATION(IT) E <br /> Auto shut off failed on pump#7 causing gasoline to impact the concrete. <br /> Station used FM 186 and absorbent pads 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 /> 1213/2004 <br /> 8'46 AM <br />