MO-9103_40585_CA_UST-61_20160302

Fax:[phone] Mar 22 2016 09:12 P.01
For RBleasex This form aheuM be completed su e e
an underground storage tank (UST) system. This form is required to be submitted within 24 hours Of tlfscavery of a known or
In NC suspected release
(DWM'119E ONLY] Suspected Contamination? (Y!N) Y Fadlry ID Number AlA
:dfidtleAt# RLsk(H I,L U)!.. Confirmed GW Contamination? (Y!N), Nr Date Leek Discovered 3- l-lie
•E�8�hr6d `/(.fig yad BY Confirmed Soil Contamination ?(YIN) A/ , CommlNon-Commercal? .LV oyr
:Repoftedbj! (clmi0one):YhoF*FOXTRepen SamPieaTaken?(YM) y _-- ReglNon{egulatatl7, NOIJ
Free Product? (Y!N) Al If Yes, State Greatest
v Thickness NSA
Incident Neme:
Address: 4390 M o r¢�
Cityrrown: A A T P-I % %V ll? (�
Latitude (dedmvd *w—): 3 S , -S4 F3 1
Brie hr describe suspected or confirmed red
eaV+n.IV vur
county. Cpk-bA r
Zip Code: 80-+s- I
Raleigh, Washington,
(� Longitude (dedraiaeg -): — go. (09 ►{ O(o
6A or S ;aj% --pr6`ii
11 ej:%Vnc 0•` v
hn)p5 n0" i 1
I.14YA
❑ Release DetectionEquipment or Methods
14 During UST Cbsure/Removai
❑ Property Transfer
etn S61
.SE WAS DISCOVERED (Release code)
(Check are)
® Visinuodor I
❑ Water in Tank
❑ Water Supply Well Contamination
Obtained by:
❑ GPs
❑ Topographic map
❑ GIS Address matching
Other
❑ Unknown
Describe location:
❑ Ground Water Contamination
❑ Surface Water Contamination
❑ other (specify)
SOURCE OF CONTAMINATION
Sgyrce of Re ease
Cause of Release
Type of Release
Product Was
Release
typ
(Check ono to indicate primary
(Check one to Indicate primsry
(Check one)
(Check one to indicate �m aty product e
source)
cause)
gl Tq„k
❑ sPm
Petroleum
❑
Gasolmat Diesel/
❑ DleseWeg. Oil
(❑ Pip"
Cl WeHlll
❑ Non-PetmlEwm
'®
Kerosene
Heating Oil
ciend
❑ Vegetable ON I00%
❑ Dispenser
9 Corrosion
❑ Both
❑
Other Petroleum
❑ E70—E20
Q Submersible Turbine Pump
❑ Physical or Mechanical
Cl
Products
❑ E21 — w
❑ Delivery Problem
Damage
Location
(Chock one)
❑
mews
Other Inorganic
❑ ESS — Egg
❑ Omer
❑ Install Problem
❑
Other Organic$
❑ Ethanol 100%
❑ Unknown
❑ OtherQ
Facility
I� Residence
❑ E01 — F09
❑ Unknown
oefin%tons prosentod on reverse
Defrndigns pfasonted on reverse
I ❑ Other
own9mbill
1. Municipal 2. Military 3. unknown 4. 5. Federal 0. County 7. State
Oporso" Sine
1. Public Service 2. Agricultural
3. 1esldentia . Education/Reiig.
S. Industrial 6_ Commercial
7. Mining

Fax:[phone] Mar 22 2016 09:13 P.02
IMPACT ON DRINKING WATER SUPPLIES
Water Supply Welk Aftchid? 1. yes 2. No 9. nknpwn
Number of Water Supply Wells Affected
Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional cheat if necessary)
1.
2.
3.
UST SYSTEM OWNER
((
UST Ownem dCopany C h r; 5 +&v) � v lry Fa wu � % l_c_
Point of Content
max CV) ("G -eve Lam r.
Address
C'7 S C ca'A v i e err °tor. PE E
CityState
Concor6/'
PAC
Zip Code Telephone Number
.1$0;-6r %9- 2q1- 71Z}
UST SYSTEM OPERATOR
UST Operator/Company
Address
city
State
Zap Code
Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
CV) els��l� �r FLlwt4�
C
Address
fQ-:� S Grak.•-A NIE
cityco"kCenot
State
I NC_
Zlp Cone
1 �2 801 5--
Telephone Number
Draw Sketch of Area (showing two major road intersections) or Attach Map
Person Reporting Inciderd', PAS se
Telephone Nimtber 764 -9 -A2
Title {
Address S� C)w....
$as v k )[
Date
UST Form 61(0=8)v CI dvr .to W-INL 1$xt-J- 'qr`
Deaeldoes of liowcas
Tank: means the teak that stmes the product and is part of the mdergrouad storage teak syst®
P;pieF~ roaeas the oinina era cranector.+unnma from the tank or submersible Whine pump to the dispenser mother eod-me equipment (Vent, vapor recovery. m fill
lines are excluded)
Dispetra rinchtdca the diapemer and the equipment used to connect the dispenser to the piping (e.g., a release from a auction pomp or from components located above
the shear valve)
Submersible Turbine Pump (STF) Area hscincim the submersible turbine pump head (typically located in the molt sump), the liac leak detector, and the piping that
connecis the suboe lble ntrbine pump to the tmk
➢slivery Problom: identifies releases that accused dozing product delivery to the tank (Typical causes associated with this scow, are spills aid overfills)
ocher: serves u the option to use wiles, the release source is known lot does lot fit into one of the preceding categmlea (erg-, for miceses from vent lines, vapor
recovery lines, and fill lines)
Unlmnwn: identifies releases for which the source bar mot been determined
Definition of Causes
Spill: use ibis cause when a spill occurs (e.g., whm tbi dclivery bosc is disconwcied from the took fill pipe m wbon the nozzle is removed from the dispenser)
overfill: ore whm an overfill ocwra (e.g., overfills may occ+u from the fill pipe at the took m when like nozzle fails to shut off at the dispenser)
Physical o Mechanical Damage: we for all types of phy.icA or mecbarical damage, mcept corrosion (e.g., puncture of tank a piping, loose fittaogs, broker
components, and components that have changed dur eneiot)
Cotmsion:use when a metal teak, piping, or other compoimt has a release due to corrosi m (e.g, for steel, wrimion takes the form of twit)
installation Problem: we whm the problem is detwmis,ed to bave occurred specifically because the UST system was not installed pmperly,
Other: use tills option when the cause is known but does not fit into one of the prmeding mcgories (e.g., putting mgulmed substmces into rawlmmg wells)
Unknown: we when the close has rot been determined

Fax'7045252051
Mar 22 2016 09:13 P.03
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