MO-6615_27296_CA_UST-61_20021113

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11/13/02 WED 12:15
FAX/1 704
541 8416
ERM-Southeast.Inc. Z 002
-`--fir
Department of Environment and Natural Resources,
Division of waste Management, Underground Storage Tank Section
24-Hour Release and UST Leak Reporting Forst
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 onn.Y) Suspected Contamination? (Y/N) 10ti Facility ID Number
Incident q o'-o-7 j `- to Risk (H.I,L,U��_ Confirmed GW Contamination? (YfN) -,LL Date Leak Discovered _L.- �;�
Received On ut �`+ -'Received B r i' r_, Confirmed Soil Contamination 7(Y/N) rnmm/Non-Commerce 17 �-
Reponcd b (circle one): Phonc,ip�r Rcport Free Product 7 (Y/N) �(_ If Yes, State Reg/Non-regulated? K
Region ,-k (ci Greatest Thickness
INCIDENT DESCRIPTION
Incident Namc: I
Address: s2'7 q+..,.do Ave—- County /h«,We,6a
Regional Office (circle one): Asheville acres" a Fayetteville,
City/Town: C1_e.rj.4+� Raleigh, Washington, Wilmington, Winston- aem
Latitude (dd.mm.ssss): Longitude (ddd.mm.ssss)Confirmed by GPS7 (YM)
Briefly describe suspected or confirmed release: (including bur not limited to nature of release, dare of releaser amount of release. amount of
free product present and recovery efforts. initial respoaset conducted. impacts !a receptors)
-As 1 / J t /o nit
C.,.�ot r.. /cT ej llor +W 1'c [.lo r..rG O I
u5T L-.6 ord er i. +�cl SC„ O $e.l SLoh �II !-,ri,C.�-r✓
L o •. '� rl.. +t a o "r F'I e. 10 / Z3 o f-L. 1/. S't• e, r ,c
HOW RELEASE WAS DISCOVERED
(Check one)
❑ Release Dctcetion Equipment or Methods ❑ visual/Odor ❑ Groundwater Contamination
During UST Closurc/Removal ❑ Water in Tank ❑ Surface Water Contamination,
❑ Property Transfer. ❑ Water Supply Well Contamination ❑ Other (sr—fy)
SOURCE OF CONTAMINATION -
Primary Source of Contamination Primary Contaminant Type Location Settin
(Check one) (Check one) (Check one) (Check one)
El Suspected UST Release �Gasolme/Diesel/Rerosene OFaciliry Residential
�Confrrmcd UST Release (Also check one below). Heating Oil ❑ Residence Industrial
❑A. Dispenser ❑ Other Petroleum Products ❑ Other Urban
❑B. Line Release ❑ Metals ❑ Rural
®C Tank Release ❑ Other Inorganics
❑D. Spill/Overfill ❑ Other Organics
®E. Exact Failure Location Unknown or
Multiple Failures
❑Unknown Source (Believed to be UST Soume,
ex inin in "Incident Description" above
Ownership
I. Municipal 2. Military 3. Unknow 4. Private . Federal 6. County 7. State
Operation Tyne
1. Public Service 2. Agricultural 3. Residential 4. Education/Rclig. 5. Industrial 6. Commercial 7. Mining
UST Form 61 (07/00) -- - - --
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11 i13i0" w'ED 1.:15 FAX [phone] ERM-Southeast,lnc. m 003
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IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Afected? 1. Yes 2. No 3. Unknown
Number of Watcr Supply Wells Affected
Water Supply Wells Contaminated' (Include Uteri Names, Addresses and Phone Numbers Attach additional sheet if necessary)
1. No+--
2.
3.
UST SYSTEM OWNER
UST Owner/Company -
T,.k ,;s MeV- k
Point of Contact
Address
As;,,e� N-.ri,
HSS .6r"- l±uc. NW
City
State
Zip Code
Telephone Number
'763 -
Al, nn4q IV 01,i
M 111
5'5-I133
70- 9oeo
UST SYSTEM OPERATOR
UST Operator/Company
Address
vi-,- h 5
S2% A+A^,lo Ave --
City '
c� qr atfc
State
IUC-
Zip Code
2B2-o6
Telephone Number
I yoy-37z-99aa
LANDOWNER AT LOCATION OF UST INCIDENT
Lando-ner Address _
Tr�r riS me�J n Ave- NW
City State Zip Code Telephone Number
Mlhn<q S M N SS`i/33 743-717- 9000
Draw Sketch of Area (showing two major road intersections) or Attach Map
Sec i4 'f l-a cJ..eoA Mwp.
Person Reponing Incident Company Telephone Number
,rrr 'P/otisee- ERM NG 4�L %0Y- gill -Q345'
Titic Address Date
?r-_<Vt Mq-. q]C- ', tr , '1-00 730o Cf.(�t I Ege C. 1, ,1 13 2pD2
'ST Form 61 (07/00) e- I-- r I„+" -e Al C- a o -
2

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