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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASELEAK /CONTAMINATION SITE REPORT <br /> EMERGENCY DES REPORT FILED :FOR LOCAL AGENCY USE ONLY <br /> YES E% NO 1E YES F-1 NO lHEREBY CERTI. .NAT!HWE CS PIBUTEU°Tfl*1 NFCRMATIDN <br /> REPORT DATE <br /> CASEN ORDNGT `ENS-IY2U TNK ShOWN OF THE SACRAGE OPTHIS FORMS <br /> 01 2) 11 21 01 5� 05-0963 <br /> M M D D V Y SIGNED DATE <br /> NAME OF INDIVIDUAL FILLING REPORT - <br /> Ian A.Ellis (336)315-2831 — o--y_ If <br /> REPRESENTING COMPANY OR AGENCY NAME <br /> REPORTED O LOCAL AGENCY O REGIONAL BOARD <br /> BY �OWNER(OPERATOR OTHER Gilbarco Veeder Rooi <br /> ADDRESS <br /> 7300 W.Friendly Ave Greensboro NC 27420-2087 <br /> STREET CITY ST MP <br /> NAME CONTACT PERSON <br /> Safeway,Inc. James Schwartz 925-469-7306 <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 95207 <br /> ADDRESS CITY ST MP <br /> CROSS STREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> AGENCIES County of San Joaquin CUPA Doug Wilson 209-468-3446 <br /> PHONE <br /> OES Joanne Phillips 800-852-7550 <br /> 1 NAME -QUANTITY TOST(GALLONS) <br /> Gasoline <br /> SUBSTANCE 1.5 gallons El <br /> INVOLVED i MANTITV LOSTIGALLONS) <br /> UNKNOWN <br /> DA It DISGOVERL HOW U=UVEREU <br /> 0 2 1 2 0 $ TANK TEST ❑TANK REMOVAL NUISANCE CONDITIONS <br /> M M D 0 Y V INVENTORY CONTROL SUBSURFACE MONITORING Seen Visually OTHER <br /> METHOD USED TO STOP DISCHARGE <br /> DATE DISCHARGE BEGAN Q UNKNOWN REMOVE CONTENTS CLOSE TANK&FILL IN PLACE Q <br /> DISCOVERY 0 21 11 21 01 5 REPAIR TANK REPAIRPIPING <br /> HAS DISCHARGE BEEN STOPPED X I YES NO <br /> & Q REPLACETANK CHANGE PROCEDURE O <br /> ABATEMENT 0 2 1 20 5 CLOSURE TANK&REMOVAL Dispenser turned off OTHER <br /> SOURCE OF DISCHARGE CAUSES) <br /> O TANK TEST UNKNOWN Q OVERFILL UNKNOWN O <br /> O PIPING LEAK OTHER ❑X E]CORROSION SPILL E] <br /> Dispenser REPTURE I FAILURE Customer overfilled OTHER ❑X <br /> CHECK--01 ONLY <br /> CASETYPE L OTHER Concrete EISOILONLY GROUNDWATER DRINKING WATER(WELLS AFFECTED) <br /> CHECK ONE ONLY <br /> CURRENT QNO ACTION TAKEN O PRELIMINARY SITE ASSESSMENT SUBMITTED POLLUTION CHARACTERIZATION O <br /> STATUS Q LEAK BEING CONFIRMED O PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS 0 <br /> O REMEDIATION PLM) ®CASE CLOSED(COMPLETED I UNNECESSARY) CLEANUP UNDERWAY 0 <br /> CHECKAPPROPRIATEACTI M ) <br /> CAP SITE(CD) EXCAVATE&DISPOSE(ED) - REMOVE FREE PRODUCT(FP) <br /> REMEDIAL O CONTAINMENT BARRIER(CS) O EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT Q <br /> ACTION O VACUUM EXTRACT(VE) Q NO ACTION REOUIREDNA) TREATMENT AT HOOKUP(HU1 O <br /> VENT SOIL(VS) ❑X OTHER See Comments ENHANCED BIO DEGRADATION(R) ❑ <br /> Customer overfilled causing gasoline to reach concrete pavement. <br /> Station used FM 186 spill kit 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 /> v1&ado5 <br /> 8:07M <br />