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UNDERGROUND STORAGt TANK UNAUTHORIZED RELEASE LEAK /CONTAMINATION SITE REPORT <br /> r EMERGENCY OES REPORT FILEDF:CfE�S194GffNCf.E4tJFY::l:i:2:::::: ::: :;:: ::: : ::?::12: :;:?2;::::::;::::::;:: <br /> YES <br /> X NO <br /> YES ES NO <br /> ❑ ❑ ❑ ❑ Ek{�F.t�B.::G'�q� ;�#:t�t�'.I#:r�lti!�.�d :;.;:;;: <br /> REPORT <br /> DATE <br /> CASE <br /> d <br /> 0 <br /> I81 . . .. .... <br /> 1 7� 0� SI 05 4832 <br /> M M <br /> D D Y <br /> Y <br /> NAME OF INDIVIDUAL FILLING REPORT PHONE <br /> Ian A.Ellis (336)315-2831 <br /> REPRESENTING COMPANY OR AGENCY NAME <br /> REPORTED =LOCALAGENCY REGIONAL BOARD <br /> BY EX OWNER/OPERATOR D OTHER Gilbarco Veeder Root <br /> ADDRESS <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 4 gallons ❑ <br /> INVOLVED 2 QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> DA I E DISCOVERED HOW DISCOVERED <br /> 0 8 1 7 0 5 ❑TANK TEST TANK REMOVAL NUISANCE CONDITIONS ❑ <br /> M M D D Y Y ❑INVENTORY CONTROL ❑SUBSURFACE MONITORING Seen Visually OTHERE] <br /> METHOD USED TO STOP DISCHARGE <br /> DATE DISCHARGE BEGAN UNKNOWN REMOVE CONTENTS CLOSE TANK&FILL IN PLACE <br /> DISCOVERY 0 8 1 7 0 5 REPAIR TANK REPAIR PIPING ❑ <br /> HAS DISCHARGE BEEN STOPPED I X IYES NO <br /> & REPLACE TANK CHANGE PROCEDURE <br /> ABATEMENT 0 8 1 71 01 5 CLOSURE TANK&REMOVAL Customer vehicle evacuated OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> TANK TEST UNKNOWN OVERFILL UNKNOWN E] <br /> PIPING LEAK OTHER X CORROSION SPILL <br /> Customer Vehicle ❑REPTURE/FAILURE A Hole in customer gas tank �X <br /> CHECK ONE ONLY <br /> CASE TYPE F 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/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 REOUIRED(NA) TREATMENT AT HOOKUP(HU) <br /> VENT SOIL(VS) ❑X OTHER See Comments ENHANCED BIO DEGRADATION(IT) ❑ <br /> A hole in customer gas tank 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 /> 8/26/2005 <br /> 7:39 AM <br />