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• UNDERGROUND STORAtic TANK UNAUTHORIZED RELEASE LEAK /CONTAMINATION SITE REPORT <br /> EMERGENCY OES REPORT FILED EPOR LOCAL AGENCY USE ONLY '- - - � <br /> YES r7X NO EKI YES 1:1 NO THEREBY CERTIFY THAT r HAVE DISTRIBUTED THIS INFORMATION <br /> REPO CASE# ACCORDING TO THE DISTRIBUTION SHOWN OF THE BACK PAGE OFTHIS FORM.- <br /> 01 31 31 11 11 1� 11-1415 <br /> M M O D Y Y SIGNED _ _ DATE <br /> NAME OF INDIVIDUAL FILLING REPORT <br /> Jason Patriquin (336)3152816 <br /> REPRESENTING COMPANY OR AGENCY NAME <br /> REPORTED O LOCAL AGENCY El REGIONAL BOARD <br /> BY FX OWNERVOPERATOR OTHER i GilbarcoVeederRoot R CEIVE <br /> ADDRESS <br /> 7300 W.Friendly Ave Greensboro NC APR 0 4 27420-2087 <br /> STREET CRY Si <br /> NAME CONTACT PERSON <br /> Safeway-' North California Stan Olea ENVIRON 6ftlT,%7f7MTH <br /> RESPONSIBLE PER <br /> PARTY ADDRESS <br /> 5918 Stoneridge mall rd Bldg 6000,2nd floor <br /> Pleasanton CA 94588 <br /> STREET Cm ST ZIP <br /> ACILRY NAME OPERATOR PHONE <br /> Safeway-Nor Cal MANAGER 209-461-5555 <br /> SITE <br /> LOCATION 6425 N Pacific Stockton CA 95207 <br /> ADDRESS CITY ST ZIP <br /> CROSS STREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> AGENCIES SAN JOAQUIN County Robert Lopez 209468-3446 <br /> PHONE <br /> DES Blake 800-852-7550 <br /> 1 NAME QUANIITY LOST(GALLONS. <br /> Gasoline <br /> SUBSTANCE 2 gallons EX <br /> INVOLVED 2 QUANTITY LOST(GALLONS <br /> E]UNKNOWN <br /> O 3 0 8 1 1 �TANKTEST ❑TANK REMOVAL NUISANCE CONDITIONS <br /> M M D D Y Y INVENTORY CONTROL n SUBSURFACE MONITORING Seen Visually OTHER <br /> METHOD USED TO STOP DISCHARGE <br /> DATE DISCHARGE BEGAN O UNKNOWNREMOVE CONTENTS CLOSE TANK&FILL IN PLACE O <br /> DISCOVERY 0 3 0 8 11 1 REPAIR TANK REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED X YES L_fNO <br /> & REPLACE TANK CHANGE PROCEDURE O <br /> ABATEMENT 0 ! 2 <br /> 8 1 1 CLOSURE TANK&REMOVAL See comments OTHER® <br /> SOURCE OF DISCHARGE CAUSES) <br /> O TANKTEST UNKNOWN O OOVERFILL UNKNOWN 0 <br /> PIPING LEAK OTHER FXJ ❑CORROSION SPILL <br /> Dispenser REPTURE/FAILURE Auto shutoff failure OTHER �X <br /> CHECK ONE ONLY <br /> CASE TYPE OTHER concrete ❑SOIL ONLY GROUNDWATER DRINKING WATER(WELLS AFFECTED) Ej <br /> CHECK ONEON <br /> CURRENT NO ACTION TAKEN O PRELIMINARYSTIEASSESSMENTSUBMTTTED POLLUTION CHARACTERIZATION O <br /> STATUS Q LEAK BEING CONFIRMED O PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS O <br /> O REMEDIATION PLAN ®CASE CLOSED(COMPLETED I UNNECESSARY) CLEANUP UNDERWAY ❑ <br /> CHECKAPPROPRIATE ACT10 (S) <br /> CAP SITE(CD) F-1 EXCAVATE&DISFOSE(ED) REMOVE FREE PROOUCT(FP) <br /> REMEDIAL . O CONTAINMENT BARRIER(CB) O EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) O <br /> ACTION O VACUUM EXTRACT(VE) NO ACTION REOUIRED(NA) TREATMENTATHOOKUP(HU) 0 <br /> VENT SOIL(VS) ❑X OTHER See Comments ENHANCED BIO DEGRADATION(M <br /> Customer was fueling on dispenser#6 and the auto shutoff failed causing fuel to impact concrete only. <br /> As a result 2 gallons of fuel impacted the concrete.No fuel impacted the storm drain or soil. <br /> COMMENTS Fuel was cleaned up with spill kit(FM 186 hydro carbon cleaner agent)and absorbent pads. <br /> Safeway has responded to this issue and all necessary action has been taken.No further actions are currently planned. <br /> 3:9646PM <br />