MO-4471_14645_CA_UST-61_20130923_Spill Report & UST Site Visit (not added to database)

FROM :
FAX NO. : Oct. 17 2013 05:30PM P2
For tTIQ{a AA+s l Ii I* nl,.,��...�.__.
an undargrounO store tAnk
in NC
(DWm UK OILY)
Rgiceivod an Plsoefved sy,
Reported by a ano): Phonp. Foy et Report
Re*u
Incident Name:
Addreda: 14 �wy I
citymwm
ILMItude (dedmal ctmmm-)=
of
t a0mittad to the V Sartion-a regldnsl afloe folhWAN) 61 I(nOwn or suspecw0 nareaev noon
is to t)e subM tW within 24 hours of diPCOVary a a known or
T) system. This form squired
sumeated r0eaad
Suspeoted CondAmination? (YIN)
Faaillky ID Number
Conflrmad GW Conte rninstlen? (YIN
Confirmed Sal Centstni on 7(YIN
Samples Tak0n7(Y/N)
Data Leak pieW�vAlwd
Comm/N90-Cammercla17 6MM
RepMon-ro9utaeed?
Free Produtt? (YIN) _ _ t Yee, State Grea ""t
��
Th1Cknlse —
ICIDPNT DESCRIPTION
County: t'el
ap anal Otfice (cft o lone): nth-ffle, svi ayattdvl
Zip Code: $ a S Raleigh. warNngton. VNlmingWn, Winstdn
Longitude (04COM87 dam) : Obtalred by:
(inOlttdhlD but rrot r;0tA to: nature of releaft, a olf of rgrease, arr*urif 13 raps
t'eowv e s initlaMl rp4 sae con rnr cts to recp
❑ TopMraphio rno
t } , GIB Address matching
Other
Jel
© Unknown
bd
Describe location:
Drv�6t6?k 1l� eA1
Ji t a.�.'Ir� W bale.se. .fit U--MA
RELEASE WAS 111103COVERED (RaWomCo0e) rt
(Check orre)
❑ Rolamm Detection EgWpMant or WthOds ❑ viau,al/oder
() pyving UST 010AWpiRemaml ❑ Water In Tank
0 Property Transfer 0 watw Supply Wen Carttaminotlon
SOURCE OF (CANTAMINATII
Cain of _Rglqfift Type of Relent
(Gheak one to rndicato pdmvary (Cheap arie to lndcato primary (Check ore)
soup) _ causa)
C3 Tank Spin ❑ Petroleum
C3 Piping 0 overfill ❑ N&,-Potroleum
U Dispenser ❑ Corrosion Both
❑ 8u6 rvlble'r chine Pump ❑ Physiasl or Mechanical
0 tamudwator oontaminatlon
CI surfilGk Weyer Contamination
Other (speoify) r,-1 lr\ ►E
EMduat Type
Released
(Check one to htd1vole prlmaryP-0-1 type
rM1aalpAad)
15asollW Diesel/
❑ Dlesel/Veg- OB
arse
Blond
HeaWq Oil
G7 Vagatable Oil 100%
❑ Other Palroloum
0 E10— E20
PrOduate
❑ E21 E84
mQ u Darn4ge Location d MIWI$ T
WDelivery Prebl8rn "rA V-- (Check 0") C3 Other Inorganic& � F-85 —Egg
O Omar �+* j o.� Cl Inman Fruhlnm 0 Other Orgbn105 CI Ethanol 10VIo
other Facility
Unknown© Residence ❑ E01 E4g
Cl Unknown
Aaavrrrdorts tad On revpte la frn�ut Mrs on rgvBrse Cl Qdtar
1, M al '�, AAllttpry 5. unknown A. private . Pradwal 9. County 7, State
t
1. Public egrvice 2. Agrloultural I ResldMttel 4_ Education/Rellg. 9, Industrial Commeralel , mining
9 iq --'Z 1(5,-t % r }-r

FROM
FAX NO. : Oct. 17 2013 05:31PM P3
pro"itions of Sourcrn tank mnWm
`110.nk1 mcmm the tank that slave! the pradreS and i1 jfgrtllf tlta uadar�rattr►d gmrappc
Piping, rmomp the pipinT tltld oM OICIEA mmning fMni tho lank or submMibk yw+hinc pump to the ftpmlmor or other md•usm cqulpmotn (VMOt, vapor roaovaty, of All
ltnaa are excluded,)
bispunser, iWiUdw the digpmner tmd thv egftlpmcnt used to Cort em 1ho dippanstrr to the piOtT (e.g., a reknit $om'i suetien pump or from oompotlem logatod oboyd
the Ohetlrvalve)
Su mMgrdihle Turbinv Pump ($7.V) Area (ootudet the vubncmtble mrbiav pump broad (typically lov*! d in the tank stmrp), the lied lark detector, and ihd r0ing tint
enmrccts the tUUll mfhla turbine pump to the tank
Delivery Problem: idontiilas releapeS that OmrYMd ""It pmdttst delivM to the tarlc ([Typical Cattst a �tsoctatxid with rota source am op3lls mid ovgrtilln.)
Othar: serveh ac the apdan to usv when the t+cinese strarco is known ltut do« not fit into ono of Me praeedlna vaCtlprivs (o.16., 6r minnam 6"m vant llnan, vapor
recovery tines, and Jill ]in-)
Unknown- idcntfi"iop rejeales ibr which the ntnnae has tlotbecn determined
DeRmidaml ai Causes
griltt one this cause wh M a eplll poem (c.g., whe tiro dallvery bast is discontugoloA ham cure tank fill pipe or when the mull is r4tluovctl Rhxxrr the diapanaer}
pvarfill: use whoa as ovcr[Ill carom (a,g.. Ovtr1111p trtay occur &tan the flit pupa at the tank or wben the wade fall& to shut o£[ of the dloPmaer)
pbysicsl cs.Meobanioal Damage: uBC for all t,7" of physinl or mcchpaioa) AmMaR. eaacpt corrosion (t.g., ppnctury of tank Ot PiVinC, IQQW hAtiul$9, htttkm
comomemo, anA enrrrph-fflta that heve chanted dkWmm4rm)
(rnrresicn:we When a 3%ml urnk, piping, oratbor corttpoactttlms a release dug to Goocroaim (c.g., For steel, corrosion tdkos the form ORM)
Inatallptie n Pr4hiem: use wlttm the problerit is &farmincd to have oeotytt'et1 stied -Really because the UST t 1%0 Wo not btwWled pmpa''lY
01%grL roe tttin option when the camm is k cwn tart duos nn4 Fit into ono of tho preceding c'Wjt ies (e.g., putting n9fiaiatod cuhetanccs here nwnitonng -OW
Unknawa: usv Whoo the cause 11ss natbvatt deuemnirrad

North Carolina Department of Environment and Natural Resources
Division of Waste Management
UST Section, Corrective Action Branch (CAB)
INSPECTION REPORT
Date: RISK:
inspector:
Site Name: ��c 3 Incident Number:
�—
County: ram, UST Number:
Region: /yi2 U GPS Coordinates:
N W
Site Information Checklist
Facility Information:
Yes No
Operating facility?
Valid UST permit? Yes No
Number of tanks: Yes No
Site map/well map verified (if no, explain discrepancies in comments section)?
Yes No
Any visible spills/leaks (if yes, explain in comments sectio ? Ye No
Any visible water supply wells? Yes N If yes, distance to closest (ft.)?
Remediation System(s) Information:
System 1 System 2
System 3
System type?
Fully installed? Yes No Yes No
Yes No
Operating? Yes No Yes No
Yes No
Free product present (verified)? Yes No Yes No
Yes No
Was RP/consultant/other on site? Ye No
Name of RP: Company:
Name of consultant: Company:
Name of Other: Company:
Pictures Taken? Ye<:3�
Location of photos:
Time spent on site (hrs):
Comments: GO 9a a G, o� — ur '
`� e
c .ml g ar cA
(over)
This inspection sheet is to be placed in corresponding incident file upon completion
Version 1.0 CAB Inspection Report.xls