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&28/2013 <br />10'.41 AM <br />YES �% NO <br />YESN <br />YE�X REBORTFY THAT IHAVE DISTRIBUTED THIS INFORMATION. <br />ACCORDING TO THE DISTRIBU—N SHOWN OF THE BACK PAGE OFTHIS FORM <br />REPORT DOTE t <br />CASE <br />01 21 oj 11 3� <br />13 <br />M M D D Y Y <br />SIGNED .DATE <br />NAME OF INDIVIDUAL FILLING REPORT PHONE <br />SiGNq <br />Eric Bmesch <br />(336) 315-2699 <br />REPRESENTING <br />COMPANY OR AGENCY NAME <br />REPORTED <br />LOCALAGENCY O REGIONAL BOARD <br />BY <br />FX OWNER/OPERATOR OTHER <br />Gilbarco Veeder Root <br />ADDRESS <br />7300 W. Friendly Ave Greensboro NC 27420-2087 <br />STREET Cm ST ZIP <br />NAME <br />CONTACT PERSON <br />Safeway, Inc. <br />Rob Singh <br />925-069-7164 <br />RESPONSIBLE <br />PARTY <br />ADDRESS <br />P.O. Box 9070 Pleasanton CA 94588-3229 <br />STREET CITY ST ZIP <br />FACILITY NAME <br />OPERATOR <br />PHONE <br />Safeway- Nor Cal 2707 <br />Lisa Page <br />209-472-8600 <br />SITE <br />LOCATION <br />6425 N Pacific Stockton CA 95207 <br />ADDRESS CITY ST ZIP <br />CROSS STREET <br />LOCAL AGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />AGENCIES <br />County of San Joaquin COPA <br />Vicki Zaragoza <br />209-468-3420 <br />PHONE <br />DES <br />Bob McRae <br />800-852-7550 <br />1 NAME QUANTITY LOST (GALLONS) <br />Gasoline <br />SUBSTANCE <br />2 cups Fil <br />INVOLVED <br />2 QUANTITY LOST (GALLONS) <br />UNKNOWN <br />Dq ISC VERED <br />MOW DISCOVERED ' <br />0 3 2 5 1 3 <br />TANK TEST ❑TANK REMOVAL NUISANCE CONDITIONS <br />❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING Seen Visually x� <br />M M D D Y Y <br />METHOD USED TO STOP DISCHARGE <br />DATE DISCHARGE BEGAN OUNKNOWN <br />REMOVE CONTENTS CLOSE TANK &FILL IN PLACED <br />DISCOVERY <br />0 3 2 5 1 3 <br />EIREPAIRTANK REPAIR PIPING <br />HAS DISCHARGE BEEN STOPPED X YES NO <br />a <br />0 REPLACE TANK CHANGE PROCEDURE O <br />ABATEMENT0 <br />3 2 5 1 3 <br />CLOSURE TANK& REMOVAL Dispensing disabled OTHER <br />SOURCE OF DISCHARGE <br />CAUBE(S) <br />O TANK TEST UNKNOWN O <br />0OVERFILL UNKNOWN 0 <br />O PIPING LEAK OTHER E% <br />❑ CORROSION SPILL <br />Dispenser <br />EIREPTURE I FAILURE Customer delivery overfill OTHER ❑X <br />CHECK <br />ONE ONLY <br />CASE TYPE <br />EEOTHER Concrete LISOILONLY 11 GROUNDWATER DRINKING WATER (WELLS AFFECTED) <br />CHECK <br />ONE ONLY <br />CURRENT <br />NO ACTION TAKEN O PRELIMINARY SITE ASSESSMENTSUBMITTED POLLUTION CHARACTERIZATION <br />STATUS <br />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 />CHECKAPPROPRIATE <br />ACTION(S) <br />= CAP SITE (CD) EXCAVATE & DISPOSE(ED) REMOVE FREE PRODUCT(FP) <br />REMEDIAL <br />O CONTAINMENT BARRIER(CB) O EXCAVATE& TREAT(ET) PUMPS TREAT GROUNDWATER(GT) 0 <br />ACTION <br />O VACUUM EXTRACT(VE) O NO ACTION REOUIRED(NA) TREATMENT AT HOOKUP(HU) 0 <br />❑ VENT SOIL(VB) ❑ OTHER ENHANCED BIO DEGRADATIONT-) ❑ <br />Leaking nozzJe on dispenser 16 caused 2 cups of product to impact concrete only. <br />Station used absorbent material to clean the release. There was no impact to soil Or water. <br />COMMENTS <br />Safeway has responded to this issue and all necessary action has been taken. <br />No further actions are currently planned. <br />&28/2013 <br />10'.41 AM <br />