WS-10023_45185_CA_UST-17A_20190319

UST-17A UST Suspected Release 24 Hour Notice
Do not use this form to report a 24 hour notice of a Pollution Incident. You must use form UST-61, 24 Hour Release and UST Leak
Reporting Form.
 This form must be used to report to DEQ, within 24 hours of discovery, a Suspected Release from any of the following:
a) Failed or inconclusive leak detection or tightness test results. This includes positive test results, such as “Increase”, which
indicates the level in the UST system has increased more than 0.2 gph.
b) Unusual operating conditions which can include, but are not limited to: the erratic behavior of dispensing equipment; the
unexplained presence of water in the tank; the presence of fuel in containment sumps or interstitial spaces; or the degradation of
any equipment or element of an underground storage tank system to the point where that equipment or element can not reasonably
be expected to perform its intended function.
c) Internal inspection results such as, perforations, corrosion holes, weld failures, or other similar defects that indicate a release
could have occurred.
 If you have more than four UST systems to report suspected releases, then attach additional sheets of the UST-17A form. You only
need to list the UST systems at your site that have suspected releases.
 Within 7 days of discovery, submit a UST-17B form to document the response activities taken to investigate the suspected release.
 Please submit this form to: NCDEQ/DWM, UST Section
1646 Mail Service Center
Raleigh, North Carolina 27699-1646
OR
Fax to [phone] OR [e-mail]
I. UST OWNER II. UST FACILITY
Name:
Speedway, LLC
Name:
Speedway #6934
Facility ID:
0000015480
Address:
500 Speedway Drive
Address:
566 Old Hollow Road
City:
Enon
State:
OH
Zip:
45323
City:
Winston-Salem
County:
Forsyth
Person Reporting:
Nicole Long
Title of Person Reporting:
Project Manager (GRI)
Telephone Number:
(704) 845-4010
III. UST INFORMATION
Tank Number / Size: 4 / 3,000 / / /
Product Stored: Diesel
Location and/or source of
suspected release:
(check all that apply)
Tank
Piping
Tank Sump
Dispenser Sump
Spill Bucket
Internal Inspection
Other (Explain in
comments)
Tank
Piping
Tank Sump
Dispenser Sump
Spill Bucket
Internal Inspection
Other (Explain in
comments)
Tank
Piping
Tank Sump
Dispenser Sump
Spill Bucket
Internal Inspection
Other (Explain in
comments)
Tank
Piping
Tank Sump
Dispenser Sump
Spill Bucket
Internal Inspection
Other (Explain in
comments)
Leak detection method or
other observation that
indicates a suspected
release. (e.g., ATG, SIR,
visual contamination, fuel
in sump, etc.):
Triennial Testing
Failed/Inconclusive date or
date that leak detection
method suspected release
discovered:
3/19/2019
IV. COMMENTS
- Non-passing hydro testing received for the Diesel 11/12 dispenser-issues appears to be near the entry boot for the product line.
UST-17A Revised 10/2015 http://www.wastenotnc.org/web/wm/