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UNDERGROUND STORAGE TANK UNAUTHOR12Eo RFI FASF 11 =nto / r nAITAMINATIn N1 CITF aGcnOT <br />EMERGENCY DES REPORT FILED <br />FOR LOCAL AGENCY USE ONLY V <br />Fj YES E% NO 7 YES E] NO <br />I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION <br />ACC RDIN TO THE DIS UTI NSHOWN OF THE BACK PAGE OFTHI FORM. <br />REPORT DATE <br />CASEC <br />11 01 11 21 01 6� <br />06-6059 <br />�' �v 2 <br />MM D D Y Y <br />'S1 SIGNED PATE <br />NAME OF INDIVIDUAL FILLING REPORT <br />PHON <br />Corey McMillan <br />(336) 315-2837 <br />REPRESENTING <br />COMPANY OR AGENCY NAME <br />REPORTED <br />O LOCALAGENCV O REGIONAL BOARD <br />BY <br />F. -I OWNERIOPERATOR OTHER <br />Gilbarco Veeder Rool <br />ADDRESS <br />7300 W. Friendly Ave Greensboro NC 27420-2087 <br />STREET CITY ST ZIP <br />NAME <br />CONTACT PERSON <br />Safeway, Inc. <br />James Schwartz <br />925-469-7306 <br />RESPONSIBLE <br />PARTY <br />ADDRESS <br />P.O. Box 9070 Pleasanton CA 94588-3229 <br />STREET CITY ST ZIP <br />FACILITY NAME <br />OPERATOR <br />PHONE <br />Safeway- Nor Cal 2707 <br />Lisa Page <br />209-472-8600 <br />SITE <br />LOCATION <br />6425 N Pacific Stockton CA 95207 <br />ADDRESS CITY ST ZIP <br />CROSS STREET <br />LOCAL AGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />AGENCIES <br />County of San Joaquin CUPA <br />Doug Wilson <br />209-468-3446 <br />PHONE <br />CES <br />Toni Walthour <br />800-852-7550 <br />1 NAME QUANTITY LOST (GALLONS) <br />Gasoline <br />SUBSTANCE <br />5 gallons Q <br />INVOLVED <br />2 QUANTITY LOST (GALLONS) <br />UNKNOWN <br />IS1 <br />1 O 1 0 01 6 <br />TANK TEST TANK REMOVAL NUISANCE CONDITIONS El <br />INVENTORY CONTROL FISUBSURFACE MONITORING Seen Visually 0 <br />M M D D Y Y <br />METHOD USED TO STOP DISCHARGE <br />DATE DISCHARGE BEGAN QUNKNOWN <br />O REMOVE CONTENTS CLOSE TANK &FILL IN PLACEQ <br />DISCOVERY <br />1 01 11 01 01 6 <br />REPAIR TANK REPAIRPIPING <br />HAS DISCHARGE BEEN STOPPED X YES NO <br />8 <br />O REPLACETANK CHANGE PROCEDURE Q <br />ABATEMENT <br />11 01 11 01 01 6 <br />CLOSURE TANK & REMOVAL Dispens no disabled OTHER 71 <br />SOURCE OF DISCHARGE <br />CAUSE($) <br />Q TANK TEST UNKNOWN O <br />QOVERFILL UNKNOWN O <br />PIPING LEAK OTHER �X <br />CORROSION SPILL ❑ <br />Dispenser <br />REPTUREI FAILURE Faulty Nozzle locking spring OTHER [X <br />CHECK ONE ONLY <br />CASE TYPE <br />MOTHER Concrete ❑SOIL ONLY GROUNDWATER DRINKING WATER (WELLS AFFECTED) <br />CHECK ONE ONLY <br />CURRENT <br />QNO ACTION TAKEN PRELIMINARY SITE ASSESSMENT SUBMITTED POLLUTION CHARACTERIZATION 0 <br />STATUS <br />LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS 0 <br />REMEDIATION PLAN ® CASE CLOSED (COMPLETEDI UNNECESSARY) CLEANUP UNDERWAY <br />CHECKAPPROPRIATE ACTIONS) <br />=CAP SITE (CD) EXCAVATE &DISPOSE(EO) REMOVE FREE PRODUCT(FP) El <br />REMEDIAL <br />O CONTAINMENT BARRIER(CB) QEXCAVATE &TREAT(ET) PUMP& TREAT GROUNDWATERGID O <br />ACTION <br />O VACUUM EXTRACT (VE) NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) 0 <br />VENT SOIL(VS) OTHER ENHANCED BIO DEGRADATION(IT) Ej <br />A faulty nozzle locking spring on pump #13 caused gasoline to reach concrete pavement. <br />Station used absorbent material to clean the spill. <br />COMMENTS <br />Safeway has responded to this issue and all necessary action has been taken. <br />No further actions are currently planned. <br />10116!2006 <br />5:05 PM <br />