MO-9410_40855_CA_UST-61_20181022_UST-61

Beverly, Trudy
From: Steve Hamilton <[e-mail]>
Sent: Monday, October 22, 2018 10:25 AM
To: Beverly, Trudy
Cc: 'Scott Kilby'; [e-mail]; Ryan Osborne
Subject: [External] 10200 Arthur Davis Rd 24 HR Notice
Attachments: 2181015 Arthur Davis Rd 24 hr notice pg 1.pdf; 2181015 Arthur Davis Rd 24 hr notice
pg 2.pdf, 2181015 Arthur Davis Rd Map.pdf
Steve Hamilton- Consultant
C.E.R.T.
Carolina Environmental Response Team
PO Box 681016
Charlotte, NC 28216
704-309-4262 cell
877-505-6799 office
CONFIDENTIALITY NOTICE: This e-mail communication, including any attachments, may contain privileged or confidential information for specific individuals and is
protected by law. If you are not the intended recipient(s), you are hereby notified that any dissemination, distribution or copying of this communication is strictly
prohibited and you should delete this message and its attachments from your computer without retaining any copies. If you have received this communication in
error, please reply to the sender immediately. We appreciate your cooperation. Please consider the environment before printing this e-mail.

, s' ':S1'
Z Hour Release and UST � " I � t�,�1 l�n•
z.Ar
For Releases 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
In NC suspected release
(DWM USE ONLY)
Suspected Contamination? (Y/N) _A ----
Facility ID Number
Incident # Risk (H,I,L,U) -
Confirmed GW Contamination? (Y/N) _ 1J _
Date Leak Discover T
Received On _ Received By _-----
Confirmed Soil Contamination ?(Y/N)
Comm/Non-Commercial?
Reported by (eirrJe one): Phone, Fax or Report
Samples Taken?(Y/N) -%___
Reg/Non-regulated?
Region
Free Product? (YIN) �__ If Yes, Slate Greatest
Thickness �-
INCIDENT DESCRIPTION
Incident Name:
Address: \ZZ�Az�j r. ���� ��
County. M
� ■ � _CC,
�y,�
City/Town: ��4 \ `l Zip Code:'a0� �7
Regional Office (circle one): Asheville, Mooresville, ayetteville,
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (dedmel dagr.x):' 21',(), t 3'' j\ Longitude (AeclmW dopnnc)'����11 Y'0(2" ( L" \^j
Obtained by:
❑ GPS
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)
❑ Topographic map
❑ GIS Address matching
Other GIAt
❑Unknown
Describe location:
0%V V —Q 1 --" C ,� ,�
, s--'7'r arL w ` �` (�5 �� .-t
l�
OC 90�` 1` .�% �?rY�
��(\v'
\)`N �S `� 1 '�vK* �q %1 v \
r
HOW RELEASE WAS DISCOVERED (Release code)
(Check one)
❑ Release Detecuon Equipment or Methods ❑ Visual/Odor ❑ Groundwater Contamination
During UST Closure/Removal ❑ Water in Tank ❑ Surface Water Contamination
Property Transfer ❑ Water Supply Well 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 (Chock one) (Check one to indicate primary product type
source) cause) released)
Tank ❑Spill I*.troleum ❑ Gasoline/ Diesel/ ❑ Diosal/Veg. Oil
Kerosene Bland
Piping ❑ Overfill ❑ Non-Polroloum Heating Oil ❑ Vegntablo Oil 100%
❑ Dispenser orosion ❑ Both [) Other Petroleum ❑ E 10 - E20
❑ Submersible Turbine Pump ❑ Physical or Mechanical Products
❑ E21 E84
-
Damage Location ❑ Metals
❑ Delivery Problem
(Check one) [.] Other Inorganics ❑ E85 =-E99
❑
Install Problem
Organics lity 9 ❑Ethanol 10096
❑ Other ❑ ❑ ❑ Other Facility
❑ Unknown ❑ E01 - E09
❑ Unknown esitlence
Definitions presented on reverse I Definitions presented on reverse I Other
Ownership
1. Municipal 2. Military 3. Unknown �­t-5. Federal 6. County 7. State
Operation Type
1. Public Service 2 �gn-lturl. Residential 4. EducatiorVRelig. 5. Industrial 6. Commercial 7. Mining
UST Form 61 (02/OB) Page 1 of 2

IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected? 1.
Yes 2. No Unkno n
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
Point of Contact
Address
City
State -'-,,",,"Zip
Code
Telephone Number
UST SYSTEM OPERATOR
UST Operator/Company
Address
City
St.
Zip Code
Telephone Number
LANDOWNER AT LO TION OF UST INCIDENT
Landowner
Address
City J 1
state
KY —
Zip
TelephonetJ�umber
Draw Sketch of Area (showing two major road intersections) or Attach Map
Person Reporting Incident
Company C f
Telephone Number
Title �l -V\
Address C) VvV4 <n ]
1
Date
1 2 ZZ
vr•vnn v i tvcrvv) / Ova, Pago 2 of 2
�
Definitions of Sources
Tank: means the tank that stores the product and is pan 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 dislenwr 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 w the uutk. (Typical causes associated with this sour a ore spills and overfills I
Other: serves as the option to use when the release source is known but does not fit into one of the prvceding categories (e.g., for releases from vent lines, vapor
recovery lines, and fill lines)
Unknown: identifies releases for which the source has not been doennined
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 nuzzle is rvmoved 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

E
COEOR •T
ERROLINR ENVIR09MENTRLRESPONSETERM
Emergency Response: 877-505-6799
10200 Arthur Davis Rd., Huntersville, NC
PO Box 681016
Charlotte, NC 28216
Phone: [phone]
Fax: [phone]
www.cert-usa.com
�$5 Oulu"
U'
•. o
S
Q
0 2018' ahon! Ini. i i720ft