WS-96042_95934_CA_UST-62_20201207

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

INCIDENT DESCRIPTION
Incident Name:
Address (street number/name): County:
City/Town: Zip Code: Regional Office (circle one): Asheville, Mooresville, Fayetteville, Obtained by: GPS Electronic topographic map
GIS Address matching
Other Unknown

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
Latitude (decimal degrees): Longitude (decimal degrees)
Release discovered: (date): 12/03/2020 (time): 0350 ET

Describe impacted receptors: The release migrated to the nearby catch basin but did not impacted the
pond.
Describe initial response/abatement (time/date release stopped, cleanup begun/completed, quantity of
product soil removed, confirmation sampling): Maintenanace personnel placed absorbendt to cotnain the spill and Clean Harbors - environmental contractor arrived on site at 0600 ET and continue clean up operations.
Describe suspected or confirmed release (nature of release, time/date of release, quantity of release, amount of free FedEx Ground had a fuel spill at the fuel island due to a hole in the tank and left a puddle in the parking area of approximately 20 feet x 1 feet. Approximately 50-70 gallons of diesel fuel released at the facility fuel island.
Describe location: FedEx Facility- fuel island

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:
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
City: State Zip Code Telephone Number

SITE LOCATION MAP
Street Name: 1544 Old Greensboro Road ERTS Alert #: 123527
City, State: Kernersville, NC State Ref. # 267255
County: Forsyth County NRC Rpt. # 1293422