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UNDERGROUND STORAGE ...NK UNAUTHORIZED RELEASE (LEAKY U; AMINATION SITE REPORT <br /> EMERGENCY DES REPORT FILED 0.. <br /> YES ED NO �X YES NO IHEREQYCERFIFVTHATlF VEDISTMBU' TNIS)NFD AT)ON <br /> REPORT PATE CASE ACGQRDIN�i TtYTHEQIS[RIaU3'K>N9MDWN+JF,7HE9AQKPAc3E OFTHI3FSIHM <br /> 1� 0� 21 11 01 4� 04-5475 <br /> M M D D Y Y SIGNBt1 . TE <br /> NAME OF INDIVIDUAL FILLING REPORT <br /> v <br /> Ian A.Ellis (336)315-2831 <br /> REPRESENTING COMPANY OR AGENCY NAME <br /> REPORTED O LOCAL AGENCY O REGIONAL BOARD <br /> BY r7l OWNER/OPERATOR OTHER Gllbarco Veeder Root <br /> ADDRESS <br /> 7300 W.Friendly Ave Greensboro INC 27420-2087 <br /> STREET CITY ST ZIP <br /> NAME CONTACT PERSON <br /> Safeway, Inc. James Schmitz 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 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 /> OES Scott Marotta 800-852-7550 <br /> 1 NAME QUANTITY LOST(GALLONS) <br /> Gasoline <br /> SUBSTANCE less than 2 gallons El <br /> INVOLVED 2 QUANTITY LOST(GALLONS) <br /> E]UNKNOWN <br /> JAI I 111v ... HIM DISCOVERED <br /> 1 0 2 0 0 �TANKTEST EITANKREMOVAL NUISANCE CONDITIONS <br /> M M 0 D Y Y4 ID INVENTORY CONTROL SUBSURFACE MONITORING Seen Visually OTHER E] <br /> METHOD USED TO STOP DISCHARGE <br /> DATE DISCHARGE BEGAN QUNKNOWN REMOVECONTENTS CLOSE TANK&FILL IN PLACE Q <br /> DISCOVERY 1 0 2 0 0 41 L <br /> REPAIR TANK REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED % VES NO <br /> & REPLACE TANK CHANGE PROCEDURE 0 <br /> ABATEMENT 1 0 2 0 0 4 CLOSURE TANK&REMOVAL customers vehicle removed OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> O TANKTEST UNKNOWN 0 OOVERFILL UNKNOWN 0 <br /> O PIPING LEAK OTHER O ❑CORROSION SPILL 0 <br /> Vehicle Tank REPTURE/FAILURE Customer error OTHER �X <br /> CHECKONEONLV <br /> CASE TYPE QX OTHER Concrete SOIL ONLYGROUNDWATER DRINKING WATER(WELLS AFFECTED) <br /> CHECKONEONLY <br /> CURRENT QNO ACTION TAKEN Q 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 /> CHECKAPPINOPKIATE ACTIONS) <br /> =CAP SITE(CO) EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) <br /> REMEDIAL O CONTAINMENT BARRIER(CB) Q EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) ❑ <br /> ACTION O VACUUM EXTRACT(VE) O NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) 0 <br /> VENT SOIL(VS) OTHER ENHANCED BIO DEGRADATIONBT) <br /> A customers vehicle gas tank had a hole Causing less than 2 gallons of fuel to impact the concrete. <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.No further actions are currently planned. <br /> 1D/22R00A <br /> 7:56 AM <br />