RA-29682_48805_CA_UST-61_20221207

UST-61 24-Hour Release and UST Leak Reporting Form.
For Releases
in NC
This form should be completed and submitted to the UST Section’s regional office following a known or suspected release from
an underground storage tank (UST) system. This form is required to be submitted within 24 hours of discovery of a known or
suspected release
(DWM USE ONLY)
Incident # ________ Risk (H,I,L,U)_______
Received On ________ Received By ________
Reported by (circle one): Phone, Fax or Report
Region _______

Suspected Contamination? (Y/N) ________
Confirmed GW Contamination? (Y/N) ______
Confirmed Soil Contamination ?(Y/N) ______
Samples Taken?(Y/N) ______
Free Product? (Y/N) _____ If Yes, State Greatest
Thickness ______________

Facility ID Number ______________
Date Leak Discovered ___________
Comm/Non-Commercial? ________
Reg/Non-regulated? _____________
INCIDENT DESCRIPTION
Incident Name:
Address: County:
City/Town: Zip Code: Regional Office (circle one): Asheville, Mooresville, Fayetteville,
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): Longitude (decimal degrees) : Obtained by:
Briefly describe suspected or confirmed release: (including but not limited to: nature of release, date of release, amount
of release, amount of free product present and recovery efforts, initial responses conducted, impacts to receptors) GPS
Topographic map
GIS Address matching
Other
Unknown
Describe location:

HOW RELEASE WAS DISCOVERED (Release Code)
(Check one)
Release Detection Equipment or Methods
During UST Closure/Removal
Property Transfer
Visual/Odor
Water in Tank
Water Supply Well Contamination
Groundwater Contamination
Surface Water Contamination
Other (specify) _______________

SOURCE OF CONTAMINATION
Source of Release
(Check primary source) Cause of Release
(Check primary cause) Type of Release
(Check one) Product Type Released
(Check primary product type released)

Tank
Piping
Dispenser
Submersible Turbine Pump
Delivery Problem
Spill Bucket
 Other
Unknown

Definitions presented on reverse

Spill
Overfill
Corrosion
Physical/Mechanical
Damage
Install Problem
Other
Unknown

Definitions presented on reverse

Petroleum
Non-Petroleum
Both

Location
(Check one)

Facility
Residence
Other

Gasoline/ Diesel/
Kerosene
Heating Oil
Other Petroleum
Products
Metals
Other Inorganics
Other Organics

Diesel/Veg. Oil
Blend
Vegetable Oil 100%
 E10 – E20
 E21 – E84
 E85 – E99
 Ethanol 100%
 E01 – E09
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
UST Form 61 (02/19) Page 1 of 2

00-0-0000021728Y12/2/22N
Y
Y
NN/A"
Comm.Regulated
3317 Rolesville Road
Wendell
Wake
27591 []
N 35.847271°W -78.446045°
X
- Soil contamination suspected 12/2/22 was confirmed 12/5/22 during closure
via UVF analyses from soils collected from beneath a diesel dispenser island.
- (7) loads of soils excavated from beneath the diesel island were disposed of
X
X
X
X
X
O
O
at a permitted facility. UVF samples collected at the limits of excavation confirm
cleanup to below NCDEQ Action Levels. A pit bottom risk-based sample was
submitted for lab analyses. All USTs and piping have been removed from the site.
X
BJs Grocery

IMPACT ON DRINKING WATER SUPPLIES

Water Supply Wells Affected? 1. Yes 2. No 3. Unknown

Number of Water Supply Wells Affected __________________
Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)

1.
2.
3.
UST SYSTEM OWNER
UST Owner/Company
Point of Contact Address
City State Zip Code Telephone Number
UST SYSTEM OPERATOR
UST Operator/Company Address
City State Zip Code Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner Address
City State Zip Code Telephone Number
Draw Sketch of Area (showing two major road intersections) or Attach Map
Person Reporting Incident Company Telephone Number
Title Address Date
UST Form 61 (02/19) Page 2 of 2

Definitions of Sources
Tank: means the tank that stores the product and is part of the underground storage tank system
Piping: means the piping and connectors running from the tank or submersible turbine pump to the dispenser or other end-use equipment (Vent, vapor recovery, or fill
lines are excluded.)
Dispenser: includes the dispenser and the equipment used to connect the dispenser to the piping (e.g., a release from a suction pump or from components located above
the shear valve)
Submersible Turbine Pump (STP) Area includes the submersible turbine pump head (typically located in the tank sump), the line leak detector, and the piping that
connects the submersible turbine pump to the tank
Delivery Problem: identifies releases that occurred during product delivery to the tank. (Typical causes associated with this source are spills and overfills.)
Other: serves as the option to use when the release source is known but does not fit into one of the preceding categories (e.g., for releases from vent lines, vapor
recovery lines, and fill lines)
Unknown: identifies releases for which the source has not been determined

Definitions of Causes
Spill: use this cause when a spill occurs (e.g., when the delivery hose is disconnected from the tank fill pipe or when the nozzle is removed from the dispenser)
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)
Physical or Mechanical Damage: use for all types of physical or mechanical damage, except corrosion (e.g., puncture of tank or piping, loose fittings, broken
components, and components that have changed dimension)
Corrosion: use when a metal tank, piping, or other component has a release due to corrosion (e.g., for steel, corrosion takes the form of rust)
Installation Problem: use when the problem is determined to have occurred specifically because the UST system was not installed properly
Other: use this option when the cause is known but does not fit into one of the preceding categories (e.g., putting regulated substances into monitoring wells)
Unknown: use when the cause has not been determined

O
Sara Robertson
See Attached Map
H Nemargut
Consulting Engineer
Henry Nemargut Engineering Services [phone]
12/7/20222211 Chestnut St, Wilmington, NC 28405
4225 Bermingham Way
Wendell
STMAK, Inc.
NC 27591 [phone]
Sara Robertson
NC 27591 [phone]
Raleigh
Sara Robertson