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UNDERGROUND STORAGft UNAUTHORIZED RELEASE (LEAK)/ TAMINATION SITE REPORT <br /> EMERGENCY OES REPOT FILED FOR LOCAL AGENCY USE ONLY <br /> VES FX NO 1E YES n NO IHEREBYCERTIEYTHATIHAVE DISTRIBUTED THIS INFORMATION <br /> REPORT DATE CASEY ACCORDING TO THE DISTRIBUTON SHOWN OF THE BACK PAGE OFTMIS FORM. <br /> 01 2� 01 31 11 2� 12-0689 <br /> M M D D V V SIGNED _ - DATE _ <br /> NAME OF INDIVIDUAL FILLING REPORT <br /> Jason Patdquin (336)3152816 <br /> REPRESENTING COMPANY OR AGEN VNAME <br /> REPORTED r_7LOCAL AGENCY REGIONAL BOARD <br /> BY F.-I OWNER/OPERATOR E-1 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 9458E <br /> STREET CTY ST ZIP <br /> FACILITY NAME OPERATOR PHONE <br /> Safeway-Nor Cal MANAGER 209472-8600 <br /> SITE <br /> LOCATION 6425 N Pacific Stockton CA 95201 <br /> ADDRESS CITY ST ZIP <br /> CROSS STREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> AGENCIES SAN JOAQUIN County Voicemail 209-468-3440 <br /> PHONE <br /> OES Rueben R. 800-852-7550 <br /> 1 NAME QUANTTTYLCST(GALLONE <br /> Gasoline <br /> SUBSTANCE 1.08 gallons ❑X <br /> INVOLVED 2 OUANTITY LOST(CALLOW <br /> UNKNOWN <br /> Hu <br /> 0 2 0 3 1 2 �TANKTEST TANK REMOVAL NUISANCE CONDITIONS Ej <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 O REMOVE CONTENTS CLOSETANKB FILL IN PLACE 0 <br /> DISCOVERY () 21 01 3 1 2 ❑REPAIR TANK REPAIR PIPING ❑ <br /> HAS DISCHARGE BEEN STOPPED X YES NO <br /> g REPLACE TANK CHANGE PROCEDURE O <br /> ABATEMENT 0 2 0 3 1 2 CLOSURE TANK 8 REMOVAL See comments OTHER <br /> SOURCE OF DISCHARGE CAUSES) <br /> �TANKTEST UNKNOWNO XO OVERFILL UNKNOWN <br /> O PIPING LEAK OTHER �X CORROSION SPILL <br /> Customer error �REPTURE/FAILURE See comments OTHER <br /> CHECKO EONLY <br /> CASE TYPEOTHER Concrete ❑SOIL ONLY GROUNDWATER DRINKING WATER(WELLS AFFECTED) <br /> CH CKONEONLY <br /> CURRENT NO ACTION TAKEN O PRELIMINMVSREASSESSMENTSUBMITED POLLUTION CHARACTERIZATION <br /> STATUS O LEAK BEING CONFIRMED O PREUMINARYSITEASSESSMENTUNDERWAY POST CLEANUP MONITORING IN PROGRESS O <br /> O REMEDIATION PLAN ®CASE CLOSED(COMPLETED/UNNECESSARY) CLEANUP UNDERWAY E] <br /> CHECKAP ROPRIA TIONS) <br /> CAP SITE(CD) �EXCAVATE 8 DISPOSQED) REMOVE FREE PRODUCT(FP) <br /> REMEDIAL CONTAINMENT BARRIER(CS) O EXCAVATE B TREAT(ET) PUMP a TREAT GROUNDWATER(GT) O <br /> ACTION O VACUUM EXTRACT(VE) O NO ACTION REQUIRED(NA) TREATMENTATHOOKUP(HU) <br /> VENTSOIL(VS) ❑X OTHER Sea Comments ENHANCED BIO DEGRADATICN(IT) <br /> Older customer was fueling on dispenser number 4 and squeezed the nozzle while the hose was out of their gas tank. <br /> As a result,1.08gallons of fuel impacted concrete only. <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 p nne . FEB 15 202 <br /> s titi, 2 �Z <br /> PERMIT/SERVICES <br /> vtarzm2 <br /> 3:28 PM <br />