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IF <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY <br />DES HIEPOR'I FILED <br />0 YES <br />�X NO <br />❑X YES F-1 NO <br />REPORT DATE <br />CASE <br />01 41 01 <br />8101 5 <br />05-2142 <br />M M D <br />D V Y <br />NAME OF INDIVIDUAL FILLING REPORT <br />Ian A. Elfin <br />(336) 315-2831 <br />REPRESENTING <br />CO PANY OR AGENCY NAME <br />REPORTED <br />= LOCALAGENCY <br />O REGIONAL BOARD <br />BY <br />a OWNERIOPERATOR <br />a OTHER <br />Gilbarco Veeder Root <br />ADDRESS <br />7300 W. Friendly Ave Greensboro <br />NC 27420-2087 <br />STREET CITY <br />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 <br />Pleasanton <br />CA 94588-3229 <br />STREET <br />CITY <br />ST ZIP <br />FACILITY NAME <br />OPERATORPHONE <br />Safeway- Nor Cal 2707 <br />Lisa Page <br />209-472-8600 <br />SITE <br />LOCATION <br />6425 N Pacific <br />Stockton <br />CA 95207 <br />ADDRESS <br />CITY <br />ST til" <br />CROSS Si REET' <br />LOCAL AGENCY <br />AGENCY NAME <br />CONTACT PERSON <br />PHON <br />AGENCIES <br />County of San Joaquin <br />CUPA <br />Doug Wilson <br />209-468-3446 <br />PHONE <br />OES <br />Joanne Phillips <br />800-852-7550 <br />1 <br />NAME <br />OUANTITY LOST(GALLONSI <br />Gasoline <br />SUBSTANCE <br />3.5 gallons <br />INVOLVED <br />2 <br />QUANTITY LOST fGALL NS) <br />0 UNKNOWN <br />UA I It DiUCLIVEKIEDHOW <br />01 41 01 $ fil S <br />DISCOVERED <br />T'ANKTES'r TANK REMOVAL <br />NUISANCECONDITIONS <br />INVENTORY CONTROL SUBSURFACE MONITORING <br />Seen Visually OTHER X� <br />M. M D 0 Y Y <br />METHOD USED TO STOP DISCHARGE <br />DATE DISCHARGE BEGAN <br />QUNKNOWN <br />OREMOVE CONTEMS <br />CLOSE TANK&FILL IN F!ACE� <br />DISCOVERY <br />01 4 01 81 01 5 <br />REPAIR TANK <br />REPAIR PIPING <br />HAS OISCHARGE BEEN STOPPED x YES NO <br />& <br />0 REPLACE TANK <br />CHANGE PROCEDURE Q <br />ABATEMENT <br />01 41 01 81 01 5 <br />❑ CLOSURE TANK& REMOVAL <br />Dispenser turned off OTHER <br />SOURCE OF DISCHARGE <br />CAUSES) <br />O TANK TEST <br />UNKNOWN <br />OVERFILL <br />UNKNOWN O <br />PIPING LEAK <br />OTHER r. <br />CORROSION <br />SPILL <br />Dispenser <br />REPTURE!FAILURE <br />Auto shutoff failed OTHER <br />CHECK <br />ONE ONLY <br />CASE TYPE <br />OTHER Concrete <br />EISOILONLY GROUNDWATER <br />DRINKING WATER (WELLS AFFECTED) <br />'HECKONEONLY <br />CURRENT <br />r--] NO ACTION TAKEN <br />PRELIMINARY SITE ASSESSMENT SUBMITTED <br />POLLUTION CHARACTERIZATION O <br />STATUS <br />r --j LEAK BEING CONFIRMED <br />Q PRELIMINARY SITE ASSESSMENT UNDERWAY <br />POST CLEANUP MONITORING IN PROGRESS <br />O REMEDIATION PLAN <br />®CAS[ CLOS£D?COMPLETED I UNNECESARV) <br />r JLF.ANUPUNDERWAY O <br />CHECKAP <br />�FZOPRIATE ACTION(Sj <br />CAP SITE Op <br />EXCAVATE & DISPOSE(ED) <br />REMOVE FREE PRODUCT(FP) <br />REMEDIAL <br />O CONTAINMENT BARRIER(Clu <br />OEXCAVATE &TREAT(ET) <br />PUMP& TREAT GROUNDWATERfGT) <br />ACTION <br />Q VACUUM EXTRACT iVE) <br />rX AC TION REQUIRED(NA) <br />TREATMENT AT HOOKUP(HU) O <br />VENT S014VS) <br />1:1 OTHER See Comments <br />ENHANCED BIO DEGRADATION(n) <br />Auto shutoff failed on pump#13 Causing gasoline to impact concrete pavement. <br />Station used absorbent material to clean the spill. <br />COMMENTS <br />Safeway has responded to this issue and <br />all necessary action has been taken. <br />No further actions are currently planned. <br />W1&rzms <br />8:1& AM <br />