Laserfiche WebLink
r <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE LEAK /CONTAMINATION SITE REPORT <br /> EMERGENCY OPS REPORT FILED FOR LOCAL AGENCY USE ONLY <br /> EjYES F% NO M YES E] NO I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION <br /> REPORT OATS CASE# ACCORDING TO THE DISTRIBL mON SHOWN OF THE BACK PAGE OFTHIS FORM. <br /> 01 91 01 31 11 1� 11-5250 <br /> M M D D Y Y I --SIGNED - DATE <br /> NAME OF INDIVIDUAL FILLING REPORTNu"t <br /> Jason Patriquin (336)315-2816 <br /> REPRESENTING COMPANY OR AGENCY NAME <br /> REPORTED O LOCAL AGENCY O REGIONAL BOARD <br /> BY FX OWNER/OPERATOR OTHER Gilbarco Veeder Root <br /> ADDRESS <br /> 7300 W. Friendly Ave Greensboro NC 27420-2087 <br /> STREET CRY ST ZIP <br /> NAME CONTACT PERSON <br /> Safeway-North California Stan Olea 925467-2707 <br /> RESPONSIBLE <br /> PARTY ADDRESS <br /> 5918 Stoneridge mall rd Bldg 6000,2nd Floor <br /> Pleasanton CA 94588 <br /> STREET CITY ST ZIP <br /> FAGILffY NAME OPERATOR PHONE <br /> Safeway-Nor Cal MANAGER 209-461-5555 <br /> SITE <br /> LOCATION 6425 N Pacific Stockton CA 95207 <br /> ADDRESS CnI ST ZIP <br /> CROSS STREET <br /> LOCA-AGENCY AGENCY NAME —WWACT PERSON PHONE <br /> AGENCIES SAN JOAQUIN County Voice mail 209468-3446 <br /> HONE <br /> OES Blake 800-852-7550 <br /> 1 NAME OUANTRY LOST(GALLONS, <br /> Gasoline <br /> SUBSTANCE 1.5 gallons El <br /> INVOLVED 2 QUAN RYLOST(GALLONS: <br /> UNKNOWN <br /> 0 91 <br /> () 3 11 1 TANK TEST TANK REMOVAL NUISANCE CONDITIONS <br /> M M D D Y Y INVENTORYCONTROL E]SUBSURFACE MONITORING Seen Visually OTHER X❑ <br /> METHOD USED TO STOP DISCHARGE <br /> DATE DISCHARGE BEGAN OUNKNOWN REMOVE CONTENTS CLOSETANK&FILLIN PLACE O <br /> DISCOVERY 0 91 01 31 11 11 ElREPAIRTANK REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED X YES NO <br /> 8 O REPLACE TANK CHANGE PROCEDURE 0 <br /> ABATEMENT __2L 90 31 11 11 E]CLOSURE TANK&REMOVAL customer error OTHER <br /> SOURCE OF DISCHARGE CAUSES) <br /> O TANKTEST UNKNOWN 0 E]OVERFILL UNKNOWN 0 <br /> PIPING LEAK OTHER �% E]CORROSION SPILL <br /> customer error REPTURE/FAILURE OTHER <br /> CHECK OEON Y <br /> CASE TYPE FX OTHER concrete ❑SOIL ONLY GROUNDWATER DRINKING WATER(WELLS AFFECTED) El <br /> CHECK ONE ONLY <br /> CURRENT NO ACTION TAKEN F--j PRELIMINARY SITE ASSESSMENT SUBMITTED POLLUTION CHARACTERIZATION 0 <br /> STATUS O LEAK BEING CONFIRMED O PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS 0 <br /> O REMEDIATION PLAN ®CASE CLOSED(COMPLETED/UNNECESSARY) CLEANUP UNDERWAY <br /> CHECKAPPROPRLATE ACTION( ) <br /> =CAP SrTE(CD) r-1 EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) <br /> REMEDIAL O CONTAINMENT BARRIER(CB) OEXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) El <br /> ACTION O VACUUM EXTRACT(VE) O NO ACTION REQUIRED(NA) TREATMENTAT HCOKUP(HU) <br /> E]VENTSOIL(VS) OTHER See Comments ENHANCED BIO DEGRADATION(R) <br /> Customer was fueling on dispenser#7 diesel and the customer overfilled their tank. <br /> As a result 0.5 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 /> 9timorl <br /> 12:46 PM <br />