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UNDERGROUND STORM i ANK UNAUTHORIZED RELEASE (LEAK, . C NTAMINATION SITE REPORT <br /> EMERGENCY OES REPORT FILED FOR LOCAL AGENCY USE ONLY _ <br /> 11 YES � NO YES ❑ NO I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION <br /> REPORTE CASE# ACCORDING TO THE DISTRIBUTION SHOWN OF THE BACK PAGE OFTHIS FORM. <br /> T <br /> 0� 91 21 51 01 8� 07-6975 <br /> M M D D Y Y SIGNED - __ _-__ Q,gTE -' <br /> NAME OF INDIVIDUAL FILLING REPORT PHONE <br /> Melissa Martin (336)315-2746 <br /> REPRESENTING COMPANY OR AGENCY NAME <br /> REPORTED O LOCAL AGENCY O REGIONAL BOARD <br /> BY FX OWNER/OPERATOR O 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 /> Safeway,Inc. Butch Hobson 92569-7164 <br /> RESPONSIBLE <br /> PARTY ADDRESS <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 209-472-8600 <br /> SITE <br /> LOCATION 6425 N Pacific Stockton CA 91 <br /> ADDRESS CRY ST ZIP <br /> GROSS STREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> AGENCIES County of San Joaquin CUPA Vicky 209-468-3446 <br /> PHONE <br /> OES Dana Peterson 800-852-7550 <br /> 1 NAME OUANTrY LOST(GALLONS <br /> Gasoline <br /> SUBSTANCE 2 gallons ❑X <br /> INVOLVED 2 QUANTITY LOST(GALLONS <br /> UNKNOWN <br /> OF FIE DII <br /> 0 9 2 5 0 6 TANK TEST ❑TANK REMOVAL NUISANCE CONDITIONSM M D D Y Y ❑INVENTORY CONTROL ❑SUBSURFACE MONITORING Seen Visually 0 <br /> METHOD USED TO STOP DISCHARGE <br /> DATE DISCHARGE BEGAN =UNKNOWN O REMOVE CONTENTS CLOSE TANK B FILL IN PLACE _ <br /> DISCOVERY 01 91 21 5 D B REPAIR TANK REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED X YES NO <br /> 8 =REPLACE TANK CHANGE PROCEDURE _ <br /> ABATEMENT 01 91 21 51 01 81 ❑CLOSURE TANK&REMOVAL Dispenser disabled OTHER <br /> SOURCE OF DISCHARGE CA SE(B) <br /> O TANK TEST UNKNOWN =OVERFILL UNKNOWN 0 <br /> O PIPING LEAK OTHER ❑X ❑CORROSION SPILL <br /> Dispenser ❑REPTURE/FAILURE Auto-shutoff failure OTHER ❑X <br /> CHECK ONE ONLY <br /> CASE TYPE a]OTHER Concrete SOIL ONLY GROUNDWATER DRINKING WATER(WELLS AFFECTED) <br /> CHECK ONE ONLY <br /> CURRENT ONO ACTION TAKEN PRELIMINARY SITE ASSESSMENT SUBMITTED POLLUTION CHARACTERIZATION O <br /> STATUS O LEAK BEING CONFIRMED O PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS = <br /> O REMEDIATION PLAN ®CASE CLOSED(COMPLETED/UNNECESSARY) CLEANUP UNDERWAY = <br /> CHECKAPPROPRA FE ACTIONS) <br /> CAP SITE(CD) EXCAVATE 8 DISPOSE(ED) REMOVE FREE PRODUCT(FP) <br /> REMEDIAL O CONTAINMENT BARRIER(CB) O EXCAVATE S TREAT(ET) PUMP B TREAT GROUNDWATER(GT) <br /> ACTION O VACUUM EXTRACT BNE) XO NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) <br /> ❑VENT SOIL(VS) ❑OTHER ENHANCED BIO DEGRADATION(fTJ ❑ <br /> Auto-shutoff failure on pump number 6 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 /> 9130/2x8 <br /> 1147 AM <br />