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cm❑cnucry YES NO YESEl NO I HEREBY CERTIFY THAT I HAVE DISTRIBUTED.THIS INFORMATION <br /> REPORT DATE. CASE ACCORDING TO THE DISTRIBU""-"SHOWN OF THE BACK PAGE OTTHIS FORM. <br /> 3� 1l•br 1r 3� 1, i6 1 <br /> M -M D D Y Y I SIGNED DATE <br /> NAME OF INDIVIDUAL FILLING REPORT <br /> Nicholas E Cavonis (336)31572741 <br /> REPRESENTING I COMPANY OR AGENCY NAME <br /> REPORTED =LOCAL AGENCY REGIONAL BOARD <br /> BY E-71 OWNERVOPERATOR OTHER Gilbarco Veeder Root <br /> ADDRESS <br /> 7300 W.Fdendly Ave Greensboro NC 27420-2087 <br /> STREET CITY ST ZIP <br /> NAME CONTACT PERSON <br /> Safeway-North California Stan Olea 92567-2707 <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 209-472-8600 <br /> SITE <br /> LOCATION 6425 N Pacific Stockton CA 95207 <br /> ADDRESS CITY ST ZIP <br /> CROSS STREET <br /> LOCALAGENCY AGENCY NAME CONTACT PERSONPHONE <br /> AGENCIES SAN JOAQUIN County Garrett Backus 209-468-3420 <br /> PHONE <br /> DES Tim 800-852-7550 <br /> 1 NAME QUANTITY LOST(GALLONS) <br /> Gasoline <br /> SUBSTANCE 2 gallons Q <br /> INVOLVED 2 QUANTITY LOST(GALLONS) <br /> EIUNKNOWN <br /> DATE DISCOVERED How DISCOVERED <br /> 0 3 1 0 1 3 7TANK TEST ❑TANK REMOVAL NUISANCE CONDRIONS <br /> M M D D Y Y INVENTORY CONTROL SUBSURFACE MONITORING Seen Visually OTHER X❑ <br /> METHOD USED TO STOP DISCHARGE <br /> DATE DISCHARGE BEGAN UNKNOWN REMOVE CONTENTS CLOSE TANK&FILL IN PLACEQ <br /> DISCOVERY 0 3 1 0 1 3 REPAIR TANK REPAIR PIPING E] <br /> HAS DISCHARGE BEEN STOPPED X YES NO <br /> 8 �REPLACETANK CHANGE PROCEDURE <br /> ABATEMENT Q 3 1 1 3 CLOSURE TANK&REMOVAL Dispensing stopped OTHER <br /> SOURCE OF DISCHARGE CAUSES) <br /> =TANK TEST UNKNOWN = QOVERFILL UNKNOWN Q <br /> O PIPING LEAK OTHER ❑X 1:1 CORROSION SPILL <br /> Dispense r1 REPTURE I FAILURE Customer Error OTHER <br /> CHECK ONE ONLY <br /> CASE TYPEOTHER Concrete SOIL ONLY 1-1 GROUNDWATER DRINKING WATER(WELLS AFFECTED) <br /> CHECKONEONLY <br /> CURRENT NO ACTION TAKEN =PRELIMINARY SITE ASSESSMENT SUBMITTED POLLUTION CHARACTERIZATION O <br /> STATUS =LEAK BEING CONFIRMED =PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS O <br /> =REMEDIATION PLAN ®CASE CLOSED(COMPLETED I UNNECESSARY) CLEANUP UNDERWAY <br /> CHECKAPPROPRIATE ACTIONS) <br /> =CAP SITE(Co) F-1 EXCAVATE&OISPOSE(ED) REMOVE FREE PRODUCT(FP) <br /> REMEDIAL =CONTAINMENT BARRIER(CB) =EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) <br /> ACTION =VACUUM EXTRACT(VE) =NO ACTION REQUIRED(NA) TREATMENTATHCOKUP(HU) 0 <br /> �VENTSOIL(VS) IZI OTHER See Comments ENHANCED BIO DEGRADATIONI <br /> The spill was due to a Customer pulled the trigger before the nozzle was in the vehicle. <br /> As a result 2 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 /> 3,12/1013 <br /> 9'AI AM <br />