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' UNDERGROUND STORAGE .NNK UNAUTHORIZED RELEASE LEAK /C(,i.i"AMINATION SITE REPORT <br /> IF;MERGENCYOES REPORT FILED <br /> YES x <br /> NO <br /> X YES NO ::::.;.::.:*, : > :....::':<:;:•':::::;:.::.<.::::.; .::. :%. :.:::::::::i s:::i:::k:......:::::: . :.... <br /> ::s�#� 3 :.;.,G,�.,C� Mf...../11��.k S :. .. ;:3Q3t?,, ,�i,S,,S:{�3M1.>:.>:.::.::.s:.s:.>:.>:.»:.>:.::......;:.;::;: <br /> DEPORT DATE N <br /> CASE <br /> 91CGf 3bthtCi:C3 fEi Sb337Yi..i 3Fll$kC3CAlfEo <�F'1195:fiE3£3141#:`::`::::i is <br /> 01 91 21 21 0 <br /> 5 <br /> 05-5524 <br /> M M D D Y Y <br /> NAME OF INDIVIDUAL FILLING REPORT SIGNAI <br /> Ian A. Ellis 3336)315-2831 <br /> REPRESENTING COMPANY OR AGENCY NAME <br /> REPORTED =LOCAL AGENCY REGIONAL BOARD <br /> BY F---1 OWNER/OPERATOR OTHER Gilbarco Veeder Root <br /> r <br /> DDRESS <br /> 7300 W. Friendly Ave Greensboro NC 27420-2087 <br /> STREET CITY ST ZIP <br /> NAME CONTACTPERSON <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 AGENCYNAME CONTACTPERSON PHONE <br /> AGENCIES County of San Joaquin CUPA Doug Wilson 209-468-3446 <br /> PHONE <br /> OES Kevin Godwin 800-852-7550 <br /> 1 NAME QUANTITY LOST(GALLONS) <br /> Gasoline <br /> SUBSTANCE 112 gallon <br /> INVOLVED 2 QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> DATE DISCOVE HOW DISCOVEKIEU <br /> 0 91 <br /> 21 21 01 5 Fj TANK TEST TANK REMOVAL NUISANCE CONDITIONS <br /> M M D D Y Y INVENTORY CONTROL 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 01 91 21 2 0 5 REPAIR TANK REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED X YES NO <br /> 8 �REPLACE TANK CHANGE PROCEDURE <br /> ABATEMENT 0 1 91 21 21 25j CLOSURE TANK&REMOVAL Dispensing disabled OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> =TANK TEST UNKNOWN 0 OVERFILL UNKNOWN E] <br /> PIPING LEAK OTHER E ❑CORROSION SPILL ❑ <br /> Dispenser ❑REPTURE/FAILURE Customer Error Eil <br /> CHECK ONE ONLY <br /> CASE TYPE �X OTHER Concrete SOIL ONLY 1:1 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 /> FICAP 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) E] <br /> EIVENT SOIL(VS) �X OTHER See Comments ENHANCED BIO DEGRADATION(IT) <br /> Customer error on pump#2 caused gasoline to reach concrete pavement. <br /> Station used absorbent material 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 /> 10/3/2005 <br /> 8:55 AM <br />