MO-88901_96915_CA_UST-62_20221214

UST-62 24-Hour Notification of Discharge Form
For Non-UST This form should be completed and submitted to the UST Section’s regional office following a known or suspected release of
Releases of petroleum from a source other than an underground storage tank. This form is required to be submitted within 24 hours of discovery of a known or suspected petroleum release Petroleum in NC (DWM USE ONLY) Incident Priority Rank (H,I,L,U): Received (time/date): Received by: Region: Reported by: (circle one): Phone, Fax or Report
Suspected Contamination? Yes No
Confirmed GW Contamination? Yes No
Confirmed Soil Contamination? Yes No
Samples taken? Yes No Free product? Yes No If Yes(free product), state greatest thickness: feet
Release discovered: (date): (time):
INCIDENT DESCRIPTION Incident Name:
Address (street number/name): County:
City/Town: Zip Code: Regional Office (circle one): Asheville, Mooresville, Fayetteville, Latitude (decimal degrees): Longitude (decimal degrees) Obtained by: GPS Electronic topographic map
GIS Address matching
Other Unknown Describe location:
Describe suspected or confirmed release (nature of release, time/date of release, quantity of release, amount of free

Describe initial response/abatement (time/date release stopped, cleanup begun/completed, quantity of product soil removed, confirmation sampling):

Describe impacted receptors:

HOW RELEASE WAS DISCOVERED (Release Code)
(Check one) Observation of Release at Occurrence Visual or Olfactory Evidence Soil Contamination Groundwater Contamination
Water Supply Well Contamination Surface Water Contamination Other (specify)
SOURCE OF CONTAMINATION Source of Release Cause of Release Type of Release Product Type Released
(Check one to indicate primary (Check one to indicate primary (Check one) (Check one to indicate primary petroleum product source) cause) type released)
AST (tank)
AST Piping/ Dispenser
AST Delivery Problem
OTR Vehicle Tank
OTR Bulk Transport Tank
RR Bulk Transport Tank
Transformer
Unknown
Other

Definitions presented on reverse

Spill (Accidental)
Spill (Intentional)
Corrosion
Physical or Mechanical
Damage
Equipment Failure
AST Overspill
AST Installation Problem
Unknown
Other
Definitions presented on reverse

Petroleum
Both Petroleum & Non-Petroleum
Location (Check one)
Facility
Residence
Highway/Road
Railway
Other
Gasoline/ Diesel/ Diesel/Veg. Oil Kerosene
E11 – E20 Vegetable Oil 100%
E21 – E84 Heating Oil
E85 – E99 Waste Oil
Ethanol 100% Mineral Oil-no PCBs
Mineral Oil-PCBs
Other Petroleum Products
Ownership 1. Municipal 2. Military 3. Unknown 4. Private 5. Federal 6. County 7. State Operation Type 1. Public Service 2. Agricultural 3. Residential 4. Education/Relig. 5. Industrial 6. Commercial 7. Mining
Guidance presented on reverse
UST Form 62 (04/10) Page 1 of 2
IMPACT ON DRINKING WATER SUPPLIES Water Supply Wells Affected? 1. Yes 2. No 3. Unknown Number of Water Supply Wells Affected
List of Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary) 1. 2. 3.
PARTY RESPONSIBLE FOR RELEASE
(if the source of the release is not an AST system or if it is an AST system and there is a responsible party other than the AST system owner/ operator)
Name of Person/Company: Address:
City: State Zip Code Telephone Number
AST SYSTEM OWNER (if the source of the release is an AST system)
AST Owner/Company Address
City State Zip Code Telephone Number
AST SYSTEM OPERATOR (if the source of the release is an AST system)
UST Operator/Company Address
City State Zip Code Telephone Number
LANDOWNER AT LOCATION OF INCIDENT
Landowner Address
City State Zip Code Telephone Number
Draw Sketch of Area or Provide Map (showing incident site, location of release, two major road intersections, potential
receptors) Attach sketch or map to form.
Give Directions to Incident Site Attach directions to form if necessary.
Person Reporting Incident: Company: Telephone Number:
Title: Address: Date:
UST Form 62 (04/10) Page 2 of 2 Definitions of Sources AST (Tank): means the tank is used to store product AST Piping: means the piping and connectors running from the tank to the dispenser or other end-use equipment AST Dispenser: includes the dispenser and the equipment used to connect the dispenser to the piping AST Delivery Problem: identifies releases that occurred during product delivery to the tank. OTR Vehicle Tank: means the tank is used to store product to fuel an over the road vehicle OTR Bulk Transport Tank: means a tank that is used to transport product in bulk over the road (by truck) RR :bulk Transport Tank: means a tank that is used to transport product in bulk by train Transformer: means electrical transformer Other: serves as the option to use when the release source is known but does not fit into one of the preceding categories Unknown: identifies releases for which the source has not been determined Definitions of Causes Spill (Accidental): use this cause when a spill occurs accidentally(e.g., when the delivery hose is disconnected from a fill pipe) Spill (Intentional): use this cause when a spill occurs intentionally (e.g., intentional dumping or breakage) Corrosion: use when a metal tank, piping, or other component has a release due to corrosion Physical or Mechanical Damage: use for all types of physical or mechanical damage, except corrosion Equipment failure: use when a release occurs due to equipment failure other than corrosion or physical or mechanical damage AST Overfill: use when an overfill occurs (e.g., overfills may occur from the fill pipe at the tank or when the nozzle fails to shut off at the dispenser) AST Installation Problem: use when the problem is determined to have occurred specifically because the AST system was not installed properly Other: use this option when the cause is known but does not fit into one of the preceding categories Unknown: use when the cause has not been determined Guidance: Ownership and Operator Type Ownership select the category which describes owner of the AST system, bulk transport tank, or other release source Operator Type select the category which describes the operation in which owner uses the AST system, bulk transport tank, or other release source
Emergency Response and Training Solutions
ERTS
11231 Phillips Industrial Blvd. Bldg. 1, Ste 300 ● Jacksonville, FL 32256 ● USA
phone number: 440.349.2700 | fax number: 440.349.6713
ertsonline.com

My contact info:
Keith Witkowski
Project Manager
Emergency Response & Training Solutions
Corporate Office Address
11231 Phillips Industrial Blvd East – Suite 300
Jacksonville, FL. 32256
Direct : 440-349-2700 x307
E – Fax : [phone]
Mobile : [phone]
[e-mail]

Initial Photos
|
\ /

Emergency Response and Training Solutions
ERTS
11231 Phillips Industrial Blvd. Bldg. 1, Ste 300 ● Jacksonville, FL 32256 ● USA
phone number: 440.349.2700 | fax number: 440.349.6713
ertsonline.com

Emergency Response and Training Solutions
ERTS
11231 Phillips Industrial Blvd. Bldg. 1, Ste 300 ● Jacksonville, FL 32256 ● USA
phone number: 440.349.2700 | fax number: 440.349.6713
ertsonline.com

Emergency Response and Training Solutions
ERTS
11231 Phillips Industrial Blvd. Bldg. 1, Ste 300 ● Jacksonville, FL 32256 ● USA
phone number: 440.349.2700 | fax number: 440.349.6713
ertsonline.com