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UNDERGROUND STORAGe TANK LINALITHnR17Ff1 RFI FASF 11 FA141 i CnIJTAN1111d A Tinid 0170 <br />---- --- <br />EMERGENCY OES REPORT FILED <br />RYES F-1 <br />-- -- .... ........... <br />FOR LOCAL AGENCY USE ONLY <br />NO rx-1 YES NO <br />I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION <br />ACCORDING TO THE DISTRIBUTION SHOWN OF THE BACK PAGE OFTHIS FORM, <br />REPORT DATE <br />DI 11 01 91 11 21 <br />CASE * <br />12-0102 <br />M M D D Y V <br />SIGNED PATE <br />NAME OF INDIVIDUAL FILLING REPORT- <br />Melissa Martin <br />(336) 315-2746 1 - <br />REPORTED <br />REPRESENTING <br />OLOCAL AGENCY REGIONAL BOARD <br />COMPANY OR AGENCY NAME <br />- <br />BY <br />� OWNEWOPERATOR OTHER <br />�I ®\, <br />Gilbarco Veeder Roo[ �® <br />ADDRESS1 <br />7300 W. Friendly Ave Greensboro NC JAN 10 201jJ420-2087 <br />STREET CITY ST ZIP <br />NAME <br />CONTACT PERSON <br />ENVIRONM <br />NTAL HEALTH <br />Safeway- North California <br />Stan Olea <br />PERM[ <br />�E§° <br />RESPONSIBLE <br />PARTY <br />ADDRESS <br />5918 Stoneridge mall rd Bldg 6000, 2nd floor <br />Pleasanton CA 945N <br />STREET CITY ST ZIP <br />FACILITY NAME <br />OPERATOR <br />PHONE <br />Safeway - Nor Cal <br />MANAGER <br />209472-8600 <br />SITE <br />LOCATION <br />6425 N Pacific Stockton CA 95206 <br />ADDRESS CITY ST ZIP <br />CROSSSTREET <br />LOCAL AGENCY AGENCY NAME <br />CONTACT PERSON <br />H N <br />AGENCIES <br />SAN JOAQUIN County <br />Directed to call Sherrilf Department -Adrienne <br />209A68-3440 <br />PHONE <br />POPES <br />Ron DeMayo <br />800-852-7550 <br />1 NAME QUANTITY LOST (GALLONE <br />Gasoline <br />SUBSTANCE <br />1/3 gallon ❑X <br />INVOLVED <br />2 QUANTITY LOST(GALLOW <br />UNKNOWN <br />U 1 0 5 1 2 <br />TANK REMOVAL NUISANCE CONDITIONS <br />M M D D Y Y <br />_jTANKTEST <br />E] INVENTORY CONTROL SUBSURFACE MONITORING Seen Visually OTHER j - <br />METHOD USED TO STOP DISCHARGE <br />DATE DISCHARGE BEGAN O UNKNOWN <br />O REMOVE CONTENTS CLOSE TANK& FILL IN PLACE ED <br />DISCOVERY <br />0 1 0 5 1 2 <br />RREPAIRTANK REPAIR PIPING <br />HAS DISCHARGE BEEN STOPPED X YES NO <br />8 <br />[-] REPIACETPNK CHANGE PROCEDURE <br />ABATEMENT <br />01 11 01 51 11 2 <br />E:1 CLOSURE TANK& REMOVAL Dispensing stopped OTHER El <br />SOURCE OF DISCHARGE <br />CAUSES) <br />O TANK TEST UNKNOWN 0 <br />XO OVERFILL UNKNOWN El <br />O PIPING LEAK OTHER ❑X <br />CORROSION SPILL <br />Dispenser <br />REPTURE/ FAILURE OTHER <br />CHECK ONE ON <br />CASE TYPE <br />FX OTHER Concrete SOIL ONLY GROUNDWATER DRINKING WATER (WELLS AFFECTED) <br />CHECK ONE ONL <br />CURRENT <br />NO ACTON TAKEN O PRELIMINARYSITEASSESSMENTSOBMfTTED POLLUTION CHARACTERIZATION O <br />STATUS <br />O LEAK BEING CONFIRMED O PRELIMINARYSITEASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS 0 <br />O REMEDIATION PLAN ®CASE CLOSED (COMPLETED/UNNECESSARY) CLEANUP UNDERWAY ❑ <br />CHECKAPPROPRIATE ACTION(S) <br />CAP SITE (CD) Fj EXCAVATE & DISPOSE(ED) REMOVE FREE PRODUCT(FP) <br />REMEDIAL <br />O CONTAINMENT BARRIER(GB) OEXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) 0 <br />ACTION <br />O VACUUM EXTRACT (VE) O NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) E3 <br />= VENT SOIL(VS) OTHER See Comments ENHANCED BIO DEGRADATION(n) <br />Customer was fueling on dispenser number 14 and overfilled their gas tank. <br />As a result 1/3 gallon of fuel impacted the concrete. No fuel impacted the stone drain or soil. <br />COMMENTS <br />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 />1/9/2012 <br />3.10 PM <br />