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UNDERGROUND STORAGI .ANK UNAUTHORIZED RELEASE (LEAK),—ONTAMINATION SITE REPORT <br />EMERGENCY <br />OES REPORT FILED <br />FOR LOCAL AGENCY USE ONLY <br />YES <br />ED NO <br />[K] YES 1:1 NO <br />I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION <br />ACCORDING TO THE DISTRIBUTION SHOWN OF THE BACK PAGE OFTHIS FORM. <br />""DATE <br />CASE # <br />01 41 01 91 01 9� <br />09-2816 <br />SIGNED <br />DATE <br />M M D D Y Y <br />NAME OF INDIVIDUAL FILLING REPORT <br />Jason Patriquin <br />(902) 6955890 <br />REPRESENTING <br />COMPANY OR AGENCY NAME <br />REPORTED <br />= LOCAL AGENCY <br />71 REGIONAL BOARD <br />BY <br />=X OWNER10PERATOR <br />F-1 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- North California <br />Stan Olea <br />925-467-2707 <br />RESPONSIBLE <br />PARTY <br />ADDRESS <br />5918 Stoneridge mall rd Bldg 6000, 2nd floor <br />Pleasanton <br />CA 94588 <br />STREET CITY <br />BT ZIP <br />FACILITY NAME <br />OPERATOR <br />PHONE <br />Safeway -Nor Cal <br />MANAGER <br />209-830-2950 x1219 <br />SITE <br />LOCATION <br />6425 N Pacific <br />Stockton <br />CA 95207 <br />ADDRESS <br />CITY <br />ST ZIP <br />CROSS STR ET <br />LOCAL AGENCY <br />AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />AGENCIES <br />SAN JOAQUIN County <br />Cheryl <br />209468-3446 <br />PHONE <br />OES <br />Tim <br />916-262-1621 <br />NAME <br />QUANTITY LOST(GALLONS' <br />Gasoline <br />SUBSTANCE <br />1 gallon El <br />INVOLVED <br />2 <br />QUANTITY LOST (GALLONS <br />UNKNOWN <br />0 41 Oil 7 0 9 <br />F �TANKTEST TANK REMOVAL <br />NUISANCECONDmONS <br />I--] INVENTORY CONTROL El SUBSURFACE MONITORING <br />Seen Visually OTHER j <br />M M D 0 Y Y <br />- <br />METHOD USED TO STOP DISCHARGE <br />DATE DISCHARGE BEGAN <br />O UNKNOWN REMOVE CONTENTS <br />CLOSETANKB FILL IN PLACE O <br />DISCOVERY <br />() 41 01 71 0 91 <br />REPAIRTANK <br />REPAIR PIPING ❑ <br />HAS DISCHARGE BEEN STOPPED <br />X YES NO <br />S, <br />REPLACE TANK <br />CHANGE PROCEDURE O <br />ABATEMENT <br />__2L_4L_01 71 01 91 <br />CLOSURE TANK S REMOVAL <br />Auto shutoff OTHER <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />O TANKTEST <br />UNKNOWN O <br />r-1 OVERFILL <br />UNKNOWN Q <br />O PIPING LEAK <br />OTHER ❑X <br />FICORROSION <br />SPILL <br />dispenser <br />REPTURE I FAILURE <br />Auto shutoff OTHER <br />CHECK ONE ONLY <br />CASE TYPE <br />EKI OTHER concrete <br />❑SOIL ONLY GROUNDWATER <br />DRINKING WATER (WELLS AFFECTED) <br />CHECK ONE ONLY <br />CURRENT <br />NO ACTON TAKEN <br />O PREUMINARYSITEASSESSMENTSUBMITTED <br />POLLUTION CHARACTERIZATION O <br />STATUS <br />O LEAK BEING CONFIRMED <br />O PRELIMINARYSITEASSESSMENT UNDERWAY <br />POST CLEANUP MONITORING IN PROGRESS 0 <br />O REMEDIATION PLAN <br />® CASE CLOSED (COMPLETEDI UNNECESSARY) <br />CLEANUP UNDERWAY <br />CHECKAPPROPRIA ACTION(S) <br />CAP SITE (CD) <br />F� EXCAVATE S DISPOSE(ED) <br />REMOVE FREE PRODUCT(FP) El <br />REMEDIAL <br />O CONTAINMENT BARRIER(CB) <br />O EXCAVATE B TREAT(ET) <br />PUMP B TREAT GROUNDWATER(GT) O <br />ACTION <br />O VACUUM EXTRACT(VE) <br />O NO ACTION REQUIRED(NA) <br />TREATMENTATHOOKUP(HU) O <br />VENT SOIL(VS) <br />�X OTHER See Comments <br />ENHANCED BIO DEGRADATION(IT) <br />Spill was due to an auto shutoff failure on dispenser #5 at site <br />As a result 1 gallon of fuel spilled on to concrete surface. <br />COMMENTS <br />Fuel was cleaned up with spill kit (FM <br />186 hydro Carbon cleaner agent) and absorbent pads. <br />Safeway has responded to this issue <br />and all necessary action has been taken. No further actions are currently planned. <br />4,B=9 <br />1:52 PM <br />