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UNDERGROUND STORAGL TANK UNAUTHORIZED RELEASE LEAK / .:ONTAMINATION SITE REPORT <br /> EM GENCV DES REPORT FILED FOR LOCAL AGENCY USE ONLY --- <br /> YES EX NO IT] YE,$ ❑ NO I HEREBY CERTIFY THAT HAVE DISTRBUTEDTHIS INFORMATION <br /> REPORT DATE GAZE ACCORDING TO THE DISTRIBUTION SHOWN OF THE BACK PAGE OFTHIS FORM. <br /> 11 21 21 91 01 91 09-8558 <br /> M M D D Y Y .-SIGNED DATE <br /> NAME OF INDIVIDUAL FILLING REPORT PHONE <br /> Brandon Eads (336)315-2806 <br /> REPRESENTING COMPANY OR AGENCY NAME <br /> REPORTED O LOCAL AGENCY REGIONAL BOARD <br /> BY ED CWNER/OPERATOR 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-North California Stan Olea 925-467-2707 <br /> RESPONSIBLE <br /> PARTY ADDRESS <br /> 5918 Stoneridge mall rd Bldg 6000,2nd Floor <br /> Pleasanton CA 94588 <br /> STREET CITY ST ZIP <br /> FACILITY 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 Doris 209.468-3446 <br /> PHONE <br /> OES Courtland 800-852-7550 <br /> I NAME QUANTITY LOST(GALLONS, <br /> Gasoline <br /> SUBSTANCE 1.5 gallons ❑X <br /> INVOLVED 2 QUANTITY LOST(GALLONS', <br /> UNKNOWN <br /> DA FL UISGOVIENIzU I HOW DISUCIVIERLD El <br /> 11 21 21 4 0 9 F-1TANKTEST TANK REMOVAL NUISANCE CONDRIONS <br /> M M D D Y Y El INVENTORY CONTROL SUBSURFACE MON(rORiNG Seen Visually OTHER X❑ <br /> METHOD USED TO STOP DISCHARGE <br /> DATE DISCHARGE BEGAN O UNKNOWN O REMOVE CONTENTS CLOSE TANK&FILL IN PEACE O <br /> DISCOVERY 11 21 2 4 0 9 REPAIR TANK REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED I X IYES NO <br /> g REPLACE TANK CHANGE PROCEDURE O <br /> ABATEMENT 1 2 2 .41 01 91 ❑CLOSURE TANK&REMOVAL customer error OTHER <br /> SOURCE OF DISCHARGE CAUSES) <br /> TANKTEST UNKNOWNXQ OVERFILL UNKNOWN 0 <br /> PIPING LEAK OTHER CORROSION SPILL <br /> customer eROr �REPTURE/FAILURE OTHER <br /> CHECK ONE ONLY <br /> CASE TYPEI � lOTHER concrete ❑SOILONLYGROUNDWATER DRINKING WATER AFFECTED) El <br /> CHEC ONEONLY <br /> CURRENT QNO ACTION TAKEN O PRELIMINARY SME ASSESSMENT SUBMITTED POLLUTION CHARACTERIZATION O <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 /> CHECKAPPROPRIATE ACTIO (S) <br /> CAP SITE(CD) EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) <br /> REMEDIAL CONTAINMENT BARRIER(CB) OEXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) <br /> ACTION O VACUUM EXTRACT(VE) O NO ACTION REQUIRED(NA) TREATMENTATHOOKUP(HU) O <br /> VENT SOIL(VS) ❑X OTHER See Comments ENHANCED BIO DEGRAOATION(M <br /> Customer was fueling on dispenser#16 and auto shutoff was enabled,the customer said the nozzle popped out of the tank. <br /> As a result 1.5 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 /> 1:49 <br /> Ps--.-. <br />- -I ----- ,:48 PM <br />