FA-30226_00000_G_RRA_20231108

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 _0-0000018740
Date Leak Discovered _9-20-2023 _
Comm/Non -Commercial? Com Reg/
Non-regulated? _Reg_
INCIDENT DESCRIPTION
Incident Name: US #1 Food Mart
Address: 2210 US Highway 1 County: Richmond
City/Town: Maxton Zip Code: 27306 Regional Office (circle one): Asheville, Mooresville, Fayetteville, Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): N 34.97676 Longitude (decimal degrees) : W 79.60195 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
X GIS Address matching
 Other
 Unknown
Describe location:
HOW RELEASE WAS DISCOVERED (Release Code)
(Check one)
Release Detection Equipment or Methods
X During UST Closure/Removal Phase II ESA for Property Transfer
Visual/Odor
 Water in Tank
 Water Supply Well Contamination

SX oil Contamination
X 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)
X 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
X Unknown
Definitions presented on reverse
PetroleumX
 Non-petroleum
 Both
Location
(Check one)
X Facility
Residence Other
X 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
il
(1) 4 ,000-gas, (2) 3,000-gas and (1) 2,000-diesel USTs were removed during September 18-20, 2023 . Soil
sample

collected from tank pit side wall

showed GRO at 1,800 mg/kg. Groundwater samples collected
from

from a temporary well adjacent to the tank pit was found to contain numerous petroleum related compounds

FA-30226
N/A L
11/7/23 KEC
FAY Emailed
Groundwater constituents detected in the TMW constructed during the IAA phase are considered commingled
with concentrations known to exist during the 2019 LSA. Conditions remain low risk and there is no evidence
that a newer release has occurred. This tank closure will be closed out using the existing NRP (KEC)
PREVIOUS RELEASE - INCIDENT 42194, closed out 7/14/2020
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:Eddie Falcocchia
Point of Contact: Eddie Falcocchia Address: P.O. Box 2603
City: Saratoga State : CA Zip Code: 95070 Telephone Number
UST SYSTEM OPERATOR
UST Operator/Company: None Address:
City: State: Zip Code: Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner: Eddie Falcocchia Address: P.O. Box 2603
City: Saratoga State: NC Zip Code: 95070 Telephone Number
Draw Sketch of Area (showing two major road intersections) or Attach Map
Person Reporting Incident Tom Will Company East Coast Environmental, PA Telephone Number 919-772-0268
Title Geologist Address 3815 Junction Boulevard, Raleigh, NC 27603 Date 10-18-23
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
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