MO-88708_91508_CA_UST-62_20180816_ UST-62 24-Hour Notification of Discharge Form

UST-6
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
Petroleum in NC discovery of a known or suspected petroleum release
(DWM USE ONLY)
Suspected Contamination? (YIN) I
Release discovered
Incident # Priority Rank (H,I,L,U)
Confirmed GW Contamination? (Y/N) tj
(time/date): •dt3:�.-..'�
Received (time/date) _ _
Confirmed Soil Contaml a(ion ?(YIN) T
94+ 7� s k
Received by _ Region
Samples taken?(Y/N) ' Free product? (Y/N) N_
Reported by (circle one): Phone, Fax or Report
If Yes(free product), state greatest thickness: feet
INCIDENT DESCRIPTION
Incident Name: T I _� � Ll_(_
._ s i� W©(��;h County:����r�s
Address (street number/name): F[ • _
Regional Office (circle one): Asheville, oaresv Fayetteville,
City/Town: ` Zip Code: t
r.�vt Ralei h, Washin ton. Wilmin tan, Winston-Salem
Latitude ecimafoaegrees): 35 - 3S� Longitude dadma agrees) SO, f . •
Obtained by:
GPS
Describe suspected or confirmed release (nature of release, time/date of release, quantity of release, amount of free
product): T cL rs..r j v,. 4,P i' D a--
❑ Electronic topographic map
s t k o �s i r L.ar , l } < <
❑ GIS Address matching
� n.r-L- :
❑ Other
Describe initial response/abatelrlellt (time/date release stopped, cleanup begun/completed, quantity of product
soil removed, confirmation sam lin , -Jr, gij
❑ Unknown
Describe location: VV'
Describe iipacted recep ors: ,
5a�1�� Q r- �� ^mow ��� cxrr k
6G l 1V.ys aln o C I`�4 • �es.5rr�
a.-y *.h .
HOW RELEASE WAS DISCOVERED (Release Code)
(Check one)
L9 Observation of Release at Occurrence ❑ Water Supply Well Contamination
❑ Visual or Olfactory Evidence ❑ Surface Water Contamination
❑ Soil Contamination ❑ Other (specify)
❑ Groundwater Contamination
SOURCE OF CONTAMINATION
Source of Release Cause of Release Type of Release Product Tvpe 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) ❑ Spill (Accidental) Petroleum EfGasaline/ o ese1v ❑ DieselNeg. Oil
❑ AST Piping/ Dispenser ❑ Spill (Intentional) ❑ Both Petroleum Kerosene Blend
❑"ST Delivery Problem ❑ Corrosion & Non -Petroleum ❑ Ell - E20 ❑ Vegetable Oil 100%
❑ OTR Vehicle Tank ❑ Physical or Mechanical ❑ E21 - E84 ❑ Heating Oil
❑ OTR Bulk Transport Tank Damage Location ❑ E135 - E99 ❑ Waste Oil
❑ RR Bulk Transport Tank ❑ Equipment Failure (Check one) ❑ Ethanol 100% ❑ Mineral Oil -no
❑ Transformer ❑ AST Overfill PCBs
❑ Facility ❑
❑ nknown ❑ AST Installation Problem Mineral Oil -PCBs
❑Residence LA
L� Other G ±rw. ❑ Unknown Other Petroleum
❑Highway/Road Products
Other"'0" rGu ant
❑ Railway
Definitions presented on reverse Definitions presented on reverse
❑ Other
Ownership
1. Municipal 2. Military 3. Unknown r4, Private 5. Federal 6. County 7. State
Operation Type
1. Public Service 2. Agricultural 3. Residential 4. Education/Relig. 5. Industrial 5. Commercia) 7. Mining
Guidance presented on reverse
UST Form 62 (04/10) 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
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 A
h
State
Zip Code
s 2-1 Z
7 phone Number
2 2 -
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.
(vw a- ,o"L. 1st l -I C' F
Person Reporting Incident �
Company
elephone Number rD _
Title
Address ,'
'13
Date _
UST Form 62 (04/10)
Definitions of Sources
'—_8 : g
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
Page 2 of
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Beverly, Trudy
From: Graham, Dan
Sent: Thursday, December 20, 2018 11:11 AM
To: Beverly, Trudy
Subject: FW: [External] J Trucking Release Report UST-62 Form & Sampling/Analyses
Attachments: J Trucking Release Report UST-62 Form.pdf
From: David Stoner <[e-mail]>
Sent: Thursday, August 16, 2018 4:33 PM
To: Graham, Dan <[e-mail]>
Subject: [External] J Trucking Release Report UST-62 Form & Sampling/Analyses
Dan,
I left you a voice mail message. I don't know if the attached release has been reported yet, but please find the UST-62
Form. I'll be overseeing the clean-up of the 2 impacted soil areas next Tuesday August 215Y and want to go over the
sampling and analyses with you.
For the diesel area which is approximately 20' x 40' 1 was thinking about 4 samples analyzed for TPH DRO. For the
gasoline area which is approximately 20' x 30' 1 was thinking about 3 samples analyzed for TPH GRO. In each case we
would have risk -based samples put on hold for analyses pending the results of the TPH samples. Please let me know if
the above sampling and analyses would be acceptable for you.
Thanks,
David
David A. Stoner, P.G., P.E.
Sr. Principal/Vice President
Shield Engineering, Inc./Action Environmental Group
4301Taggart Creek Rd.
Charlotte, NC 28208
ph. [phone]
fax [phone]
e-mail DStoner(a)ShieldEn in,�g com or DStoner(a)ActionEnviro.com
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