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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 l t �61 Flm- lot L�J 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 <dstoner@shieldengineering.com> Sent: Thursday, August 16, 2018 4:33 PM To: Graham, Dan <dan.graham@ncdenr.gov> 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. (704) 394-6913 fax (704) 394-6968 e-mail DStoner(a)ShieldEn in,�g com or DStoner(a)ActionEnviro.com Don't forget to visit our new website and sign up for our newsletter and stay up-to-date on what's going on at Shield Engineering( Click the following link to sign up (http://eepurl.com/bb5mMn). This message is intended only for the use of the addressee and may contain information that is PRIVILEGED and CONFIDENTIAL, and/or may contain ATTORNEY WORK PRODUCT. If you are not the intended recipient, you are hereby notified that any dissemination of this communication is strictly prohibited. If you have received this communication in error, please erase all copies of the message and its attachments and notify us immediately. Thank you.