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- - UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASELEAK 1 CONTAMINATION SITE REPORT <br /> EMERGENCY DES REPORT FILED FOR LOCAL AGENCY USE ONLY <br /> 0 YES El NO 1XI YES 0 NO 19EEHYDERTPYUHAi HAb'EDLSTRIEUT,DTHISINFORMATICN <br /> REPORT CASEN ACCORDING 10 T1ED IRI BUNION SHOWN OF THE BACK.PAGEOP7HISFORM <br /> - <br /> 01 11 21 11 01 5� 05-0545 <br /> M M D 0 Y Y SIGNEC GATE <br /> NAME OF INDIVIDUAL FILLING REPORT - -{ <br /> Ian A.Ellis (336)315-2831 <br /> REPRESENTING COMPANYORAGENCYNAME <br /> REPORTED O LOCAL AGENCY O REGIONAL BOARD <br /> BY O OWNER!OPERATOR OTHER Gilbarco Veeder Root <br /> ADORESS <br /> 7300 W.Friendly Ave Greensboro NC 27420-2087 <br /> STREET CITY ST LP <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 NAMEOPERATOR PH NE <br /> Safeway-Nor Cal 2707 Lisa Page 209-472-8600 <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 County of San Joaquin CUPA Doug Wilson 209-468-3446 <br /> PHONE <br /> DES Scott Marotte 800-852-7550 <br /> 1 NAME QUANTITY LOST(GALLONS) <br /> Gasoline <br /> SUBSTANCE 3-5 gallons Fil <br /> INVOLVED 2 QUANTINLOSTIGAL1 N ) <br /> UNKNOWN <br /> 0 11 173,1 05 FITANKTEST ❑TANK REMOVAL NUISANCE CONDITIONS <br /> M M D D Y Y mow U'�BCGVEIB INVENTORYCONTROL F�SUBSURFACE MONITORING Seen Visually OTHER <br /> METHOD USED TO STOP DISCHARGE <br /> DATE DISCHARGE BEGAN QUNKNOWN QREMOVE CONTENTS CLOSE TANK&FILL IN PLACEQ <br /> DISCOVERY 0 1 1 3 0 5 REPAIRTANK REPAIRPIPING <br /> HAS DISCHARGE BEEN STOPPED % YES ND <br /> 8 Q REPLACE TANK CHANGE PROCEDURE O <br /> ABATEMENT O 1 1L 31 01 51 Ej CLOSURE TANK&REMOVAL Dispenser turned off OTHER <br /> SOURCE OF DISCHARGE CAUS 51 <br /> OTANK TEST UNKNOWN O OOVERFILL UNKNOWN <br /> O PIPING LEAK OTHER ❑% ❑CORROSION SPILL <br /> Dispenser �REPTURE/FAILURE Leaking nozzle OTHER <br /> CHECK ONE ONLY <br /> CASE TYPE Efl OTHER Concrete Ej SOIL ONLY Ej GROUNDWATER DRINKING WATER(WELLS AFFECTED) <br /> CHECK ONE ONLY <br /> CURRENT QNO ACTION TAKEN Q PREUMINARY SITE ASSESSMENT SUBMITTED POLLUTION CHARACTERIZATION Q <br /> STATUS O LEAK BEING CONFIRMED Q PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS 0 <br /> O REMEDIATION PLAN ®CASE CLOSED(COMPLETED!UNNECESSARY) CLEANUP UNDERWAY <br /> HECKAPPROPRIATE ACTION(S) <br /> FJCAP SITE(CD) EXCAVATE&DISPOSELED) REMOVE FREE PRODUCT(FP) <br /> REMEDIAL O CONTAINMENT BARRIER(CB) O EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) <br /> ACTION O VACUUM EXTRACT(VE) O NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) O <br /> VENT SOIL(VS) OTHER ENHANCED SIO DEGRAOATIONTT) El <br /> Nozzle leaking on dispenser#3 caused gasoline to reach concrete pavement. <br /> Station used 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 /> 211Q2005 <br /> 2:27 PM <br />