22047_University Place Mall_RA-732_5371_DENR_1990

CID
0
POLLUTION INCIDENT/U.S.T. LEAK REPORTING FORM
1, incident:# 1 Division of Environmental Management
GROUNDWATER SECTION
2. Tabulate only TYPE OF ACTION
1. Emergency Response 3. Complaint Investlgaflon 5.: U.S.T. Look
2. Compliance InvestIgatlon 4. Routine Inventory 6, Other:_Tan, GIL*A-
A
POTENTIAL HAZARDS: 1. Toxic Chemicals 2. Radioactivity 3, Air Emmissions 4. Explosives 5. Fire
INCIDENT DESCRIPTION
Incident Locotlon/Nome
-SOA
Address
ot
City/Town
County
Teglon
Briefly Describe Incident J
S
B
ct
V kAt'
tN" "4:
1) i_Cg' 1 L
Date Incident
If L.U.S.T.. How Leak 1. Tank Gouging
5. Interstitial Monitoring
8. Other
Occurred or Leak
Detected
Was Detected
2. Vapor Monitoring
Removal
(VTank
3. GW Monitoring
7. Tightness Test
4. Contractor who tightness tested, removed tank,
or Installed leak
detection system.
PERSON REPORTING INCIDENT
T'me
Name e
Company/Agency61 c' L I ) Telephone
C
REPORTED BY: 1..flank owner/operator 2. Government agency 3. Private (3rd) party
4. Facility owner (Non-L,U.S.T.) 5, Other:
RECOMMENDED ACTION
(MULTIPLE CHOICES POSSIBLE)
1. investigation complete
3. Initiate/complete cleanup
5, Drilling support 7. Confirm leak
Continue investigation
4. Long-term remedial action
6. Issue NOV 8. Monitoring plan
Comments
D
)Responsible Party
Site Priority
CLEANUP LEAD
Ranking
2. State
D.E.M. Regional Contact
Signature
Date
GW-61 Revised 5/89

i •
POLLUTION INCIDENT/U.S.T. LEAK REPORTING FORM
MATERIALS INVOLVED
POLLUTANTS INVOLVED
AMOUNT STORED OR
TANK CAPACITY
AMOUNT LOST
IMPACT ON SURFACE WATERS
AMOUNT RECOVEREDI
Distance to Stream(ft)
WATERS AFFECTED 1. Yes 2. N 3. Potentially
F
Fish Kill 1. Yes �2, Vo
Name of Stream
Stream Class
IMPACT ON DRINKING WATER SUPPLIES
WELLS AFFECTED 1. Yes 2. N 3, Potentially
No.. of Wells
Affected
No. of Wells
Potentially Affected
G
Population Served
By Affected Wells
Estimated Population Served By
Potentially Affected Wells
Aquifer(s) Being Used
1. Water Table 2. Confined 3. Bedrock
POTENTIAL SOURCE OF POLLUTION
PRIARYSOURCE OF
PRIMARY POLLUIANT TYPE
(Select one)
POTENTIAL POLLUTION (Select one)
LOCATION
SETTING
1, Intentional dump 13. Well
1, Pesticlde/herbicide
OFacllity
1. Residential
2. Pit, pond. lagoon 14. Dredge spoil
2. Radioactive waste
2. Railroad
2. Industrial
weak -underground 15. Nonpoint source
0Gasoline/diesel
3. Waterway
urban
4. Spray irrigation
4. Heating oil
4. Pipeline
4. Rural
5. Land application
5, Other petroleum prod.
5. Dumpsite
6. Animal feedlot
6. Sewage/septage
6. Highway
H
7. Source unknown
7. Fertilizers
7, Residence
8. Septic tank
8. Sludge
8. Other
Confirmed Violation of:
9. Sewer line
9. Solid waste leachate
10. Stockpile
10. Metals
1. 15 NCAC 2L
11. Landfill
11. Other inorganics
Yes No
12. Spill -surface
12. Other organics
2• Article 21A Part I
Yes No
If other sources, list corresponding No's.
3. Article 21A Part II
Yes No
If multiple pollutant types, list corresponding No's.
4. Federal/State U.S.T. rules
Yes No
If PIRF previously submitted for Nonprimary Sources, list Incident No's.

f POLLUTICOVCIDENT/M.T. LEAK REPORTIN(WRM
POTENTIAL SOURCE OWNER -OPERATOR
Potential Source Owner -Operator
:�vhn 1�,1,Las�r
Tele hon
�D 3al-����
Company
Street Address
City � County
State
Zip Code�O�J�
1
U.S.T. EGISTERFD
SOURCE/U.S.T.
PERMIT M�
�yL�RSHIP
OPERATION TYPE
1 YES
NO
IN USE
1 N/A
0. N/A
0. N/A
0, N/A
FACILITY ID#
2YES
NO
1, Non -discharge
1, Municipal
1. Public Service
SOURCE PERMITTED
1. Yes
2. Oil terminal
2, Military
2. Agrlcultrural
FEDERAL U.S.T.
DESIGNATION
2.No
3. Landfill
3. Unknown
a Residential
PERMIT NUMBER
. Regulated
4. Mining
Private
2. Non -Regulated
4. Educational/Rell lous
9
SOURCE ON
STATE U,S,T.
ERRIS LIST
5. NPDES
5. Federal
5. Industrial
DESIGNATION
1. Yes
/�
lJ.e•Commercial
2. No
6. RCRA
6. County
6. Commercial
2. Non -Commercial
ERRIS NUMBER
7. State
7. Mining
U.S.T. LEAK PREVENTION MEASURES
REASQN FOR INCIDENT1.
Transportation
Was tank retrofitted with overfill protection?
1. Yes
2. No
2. Mechanical failure
When and by whom?
Was tank retrofitted with interior lining?
3. Facility
1. Yes
2. No
4. Inventory only
When and by whom?
5. Human error
Was tank retrofitted with cathodic protection?
1.Yes
2 No
6. Vandalism
When and by whom?
7. Unknown
ACTIONS TAKEN
Investigation, Containment, Cleanup, etc.
'l
Tom► Yl W_ i ^> rra, �, Z) $ 4 Q Cv,' :7'a r t.,,tl► Lott l n vf-- i- j o ( I 1 I 0 ac
J
Circle Appropriate Responses
Lob Samples Taken By: 1, D.E.M. 2. D.H.S. 63Responsible Party 4. None
Samples Taken Include
1, Groundwater dsoil 3. Surface Water

POLLUTION INCIDENT/U.&T. LEAK REPORTING
LOCATION OF INCIDENT
7 1/2 Min. Quad Name
r 1 _I1 11 Lai.: Deg: Min: Sec:
-' .1 li 4 �q p
Five Min. Quad Number L� : Deg : Mln : Sec
2
K
GAS
/
cw �►aw
,rs� o►w
o � e
o a a -
PAD14 tlb? 1 Nip y o a
vvs:l^LS o` 01D TANK
EW TAN45
Sketch Should Identify The Following
I. Pollutant Source(s) 2, Impacted and Threatened Water Supplies
3. Direction of Overland Flow 4. Slgnlflcant Recharge and Discharge Features 5. Relative Physica! Structures (roads,
bulldings, etc.)
6. North Arrow 7. Scale