WI-96044_96931_CA_UST-62_20230201

UST-62 24-Hour Notification of Discharge Form
For Non-UST
Releases of
Petroleum in NC
This form should be completed and submitted to the UST Section’s regional office following a known or suspected release 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
(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? (Y/N) ___
Confirmed GW Contamination? (Y/N) ___
Confirmed Soil Contamination ?(Y/N) ___
Samples taken?(Y/N) ___ Free product? (Y/N) ___
If Yes(free product), state greatest thickness: _____feet
Release discovered
(time/date):______________
_______________________
INCIDENT DESCRIPTION
Incident Name:
Address (street number/name):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:
Describe suspected or confirmed release (nature of release, time/date of release, quantity of release, amount of free
product):
GPS
Electronic topographic map
GIS Address matching
Describe initial response/abatement (time/date release stopped, cleanup begun/completed, quantity of product
soil removed, confirmation sampling):
Other
Unknown
Describe impacted receptors: Describe location:
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
(Check one to indicate primary
source)
Cause of Release
(Check one to indicate primary
cause)
Type of Release
(Check one)
Product Type Released
(Check one to indicate primary petroleum product
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 Overfill
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/
Kerosene
E11 – E20
E21 – E84
E85 – E99
Ethanol 100%
Diesel/Veg. Oil
Blend
Vegetable Oil 100%
Heating Oil
Waste Oil
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
Y
N
N 1-26-2023 @ tbd hours
Y
Diesel Fuel Release Incident
US 71 @ Scotts Hill Loop Road Pender
Burgaw
34.319667N -77.767663W
Motor vehicle collision resulted in a diesel fuel release (estimated 50 gallons) from a damaged vehicle fuel tank.
✔
Impacted soil was excavated and confirmation samples were collected (on 1/31/2023)
None Roadway
\
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
M&W Land Improvement 1164 Kellum Loop Road
Jacksonville NC 27546 910-238-4637
Same
Same
NCDOT (District 3 Engineers Office) 300 Division Drive
Wilmington NC 28401 910-341-2000
See Attached
Joe Beaman, P.G.Highlands Environmental Solutions, Inc. 919-848-3155
Principal Geologist 8410-D Falls of Neuse Road; Raleigh, NC 27615 2-1-2023
500 ft
N➤➤N