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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE LEAK /CONTAMINATION SITE REPORT <br /> EMERGENGY OES REPORT FILED FOR LOCAL AGENCY USE ON LY <br /> ❑ YES EX NO Fx-1 VES ❑ NO I HEREBY CERTIFY THAT I HAVE DISTRBUTED THIS INFORMATION <br /> REPORT GATE <br /> 01 5CASE# ACCORDING TO THE DISTRIBUTION SHOWN OF THE BACK PAGE OFFHISFORM. <br /> 1 01 21 01 71 07-2660 <br /> M M D D Y Y SIGNED DATE <br /> NAME OF INDIVIDUAL FILLING REPORT _ <br /> Corey McMillan 336)315-2837 <br /> REPRESENTING COMPANY OR AGENCY NAM <br /> REPORTED <br /> ,REPRESENTING <br /> O REGIONAL WARD <br /> BY FX OWNEWPERATOR El 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 /> RESPONSIRL <br /> Safeway,Inc. Butch Hobson 925-469-7164 <br /> PARTY <br /> gO0RE55 <br /> P.O.Box 9070 Pleasanton CA 94588-3229 <br /> STREET CITY ST ZIP <br /> FACILITY NAME OPERATOR PHONE <br /> Safeway-Nor Cal 2707 Lisa Page 209472-8600 <br /> SITE <br /> LOCATION 6425 N Pacific Stockton CA 95207 <br /> ADDRESS CITY ST ZIP <br /> CROSS STREET <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> AGENCIES County of San Joaquin CUPA Doug W ilson 2094683446 <br /> PHONE <br /> OES Chuck Bickinella 800-852-7550 <br /> 1 NAME QUANTITY LOST(GALLONS) <br /> Gasoline <br /> SUBSTANCE 6 gallons <br /> INVOLVED 2 QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> HOW UISCOVERED <br /> 0 $ 0 2 0 7 TANK TEST EITANKREMOVAL NUISANCE CONDITIONS <br /> M M D D Y Y ❑INVENTORY CONTROL SUBSURFACE MONITORING Seen Visually x❑ <br /> METHOD USED TO STOP DISCHARGE <br /> DATE DISCHARGE BEGAN O UNKNOWN O REMOVE CONTENTS CLOSE TANK&FILL IN PLACE <br /> DISCOVERY 0 5 0 21 01 7 REPAIR TANK REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED X I YES NO <br /> & REPLACE TANK CHANGE PROCEDURE 0 <br /> ABATEMENT0 5 0 2 0 7 CLOSURE TANKS REMOVAL Dispenser disabled OTHER® <br /> SOURCE CF DISCHARGE CAUSES) <br /> O TANK TEST UNKNOWN O 0 OVERFILL UNKNOWN E] <br /> O PIPING LEAK OTHER [X 1:1 CORROSION SPILL I] <br /> DIBp¢neeT Ej REPTURE I FAILURE Customer Error OTHER ❑X <br /> CHECK ONE ONLY <br /> CASETYPEOTHER Concrete EISOILONLY Ij GROUNDWATER DRINKING WATER(WELLS AFFECTED) <br /> CHECK ONE ONLY <br /> CURRENT NO ACTION TAKEN O PRELIMINARYSITE ASSESSMENTSUBMITTED POLLUTION CHARACTERIZATION Q <br /> STATUS O LEAK BEING CONFIRMED O PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS 0 <br /> O REMEDIATION PLAN ®CASE CLOSED(COMPLETED I UNNECESSARY) CLEANUP UNDERWAY E] <br /> CHECKA PPROPRIATE ACTIONS) <br /> =CAP SITE(CD) EXCAVATE a DISPOSE(ED) REMOVE FREE PRODUCT(FP) <br /> REMEDIAL O CONTAINMENT BARRIER(CB) O EXCAVATE&TREAT(ET) PUMP B TREAT GROUNOWATER(GT) ID <br /> ACTION O VACUUM EXTRACT(VE) X�NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) ID <br /> ❑VENT SOIL(VS) ❑OTHER ENHANCED BIO DEGRADATION(IT) El <br /> Customer error on pump#13 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 /> 60=07 <br /> 900PM <br />