WA-28321_47581_CA_UST-61_20210209

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

Facility ID Number 0-032450
Date Leak Discovered 02/09/21
Comm/Non-Commercial? Comm
Reg/Non-regulated? Regulated
INCIDENT DESCRIPTION
Incident Name: Speedway #8220
Address: 138 Third Street County: Pitt
City/Town: Ayden Zip Code: 28513 Regional Office (circle one): Asheville, Mooresville, Fayetteville,
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): 35.474879 Longitude (decimal degrees) : -77.433832 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
A leaking filter housing gasket on dispenser 14 was identified on 01/11/21. A site check was conducted at the site on 02/01/21. Upon Topographic map
Receipt of the analytical report, a release has been confirmed at the site. 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
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
Speedway, LLC
Point of Contact Charles Chiara Address 500 Speedway Drive
City
Enon
State
Ohio
Zip Code
45323
Telephone Number
[phone]
UST SYSTEM OPERATOR
UST Operator/Company Speedway, LLC Address 500 Speedway Drive
City
Enon
State
Ohio
Zip Code
45323
Telephone Number
[phone]
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner Williams Family Heirs, LLC Address 539 South Main Street
City
Findlay
State
Ohio
Zip Code
45840
Telephone Number
n/a
Draw Sketch of Area (showing two major road intersections) or Attach Map
Person Reporting Incident Joanna Alley Company Geological Resources, Inc. Telephone Number [phone]
Title Operations Manager – Monroe Address 3502 Hayes Road, Monroe, NC 28110 Date 02/19/21
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