MO-88735_91533_CA_UST-62_20190327_24-Hour Notification of Discharge Form

Notification of Discharge Report
Appendix A
Report Formats
1. Notification of Discharge Report
UST- 2 -Hour Notification of Discharge Form
For Non -UST This form should be rormpleted and submitted to the UST Section's regional office following a known or suspected
Releases of release of petroleum from a source other than an underground storage tank- This form is required to be submitted
I"ELtTOle61R1 in NC within 24 hours of discovery of a known or suspected petroleum release
(DWM USE ONLY) Suspected Contamination, tY JN) _ Release discovered
Incident # Priority Rank {H,I,L,U) Confirmed firmed GVq Cortaro:nation? ('r ;i time date). -- — Received time.date --- --
�, r:firmea Soil Csr�tamrn�� :>n : (1', NI ,
- - Received by-- - __- Region it ;fa rY'rNr
Reported by (crrcie one): Phone; Fax or Report 11if v ,staree fir. cc t;, state s eatc-t tnickrless feet i
v 7 / /i r j INCIDENT DESCRIPTION
Incident Name-St-1./' � l3 o11�
.-e,6,_t's`0 Ct,
L
Address (street number/name): '�'r"
l /l.' f� <�j't i
�` /r) ��
� •` e-,'!�!-s.L.vir� t�
Coun,y:
` .
C
City/Town ,-� � �
�i t ooe t,�
��
-------
Regional Office "circle �nc�j.
Raleigh Washingtan.
-
Ashe vdle vi aoresvilic„ ayetteville.
;Vtlrntngto7
Winston Herr.
Latitude (decir:7a! decrees}:
Longitude ('ci,( imal deareesi
a;rrc,, ��-
Describe suspected or confirmed release ;nature ul i�,Jr se. timeid rte of telease, r1ija
tity o• , f: ,se- amouni 7 ire;:
J •CF7v
5
CJ
I�
I7esc,Tbc mina! _ onseJabatement (hmeid�t release stc�ppea cep pb�., orrpf�fea q:ant, y o ;>rod'L�t soli
removed, confirmation sampling
>`
1�s.nb� mrpt�tc�3 rntrr� � j
-- <�G �4`�`ZL'_l-rr e'1_ _ ��' C-►t"�S _-1"![��-__ N��-G 3.� j jr! t���,�_ ---__
HOW RELEASE WAS DISCOVERED (Release Code)
(C,;eck one)
J Observaiion of Release at Occurrent= ®j UNater St apply `";eil Contamination
kE_1 Visual or Olfactory Evidence JSurfar:e Water f onianiinatioll
l Contamination JOther istrec;fvl
[-JGroundwaterContamination
.- - -- ---- -- - - — - --- -
Source of Release
(Check
one n: indicate pninan
Si:LirCe)
AST (tank)
AST Piping," Dispenser
U
AST Delivery Problem
`J
O (R Vehicle Tank
O
OTR Bulk Transport Tank
U
RR Bulk transport 1 ank
U
Transformer
J
Unknown
U
Other
Definitions presented on reverse
Ownership
1. Municipal 2. Military 3
SOURCE OF CONTAMINATION
Cause of Release i ype of release
ha n r>nc to nd.kace hri nary cause) Whecy one;
Spill (Accicontal)
Petrcleu ; ,,
-A
Spill (inte-r icknai
_ Both Petro .�sn
J
C•orros. Xi
-i
Physic -I U "eCn -;CaI
�.'aitiriuF
oca'tlon
J/
quiprnc rat f ailtHe
(C:hec one!
as
AST Ot er-,fi
1pP
J
AS t it Pronlet
t J r Iity
J
Unknown
Cliher.a
H}ghwaviRoad
J Railway
Deb,nibcns
prose ded on r everse ;
,J Other -
Operation Type
t Public Service 2. Agricultural( 3- R
Guidance presented on reverse �—
UST Form 62 (04110)
4. Private_,/�. Federal 6. Countt 7 State
-JClectroni topographic neap
J GIS Address matching
,d b:1i2' (G'"C'51C)
J trine .vr,
Product Type Released
(C:crt. un� Ic . ri«atc prim:.-1..cr,,•h_m> p,cduct I,pe
� vasolin�'vkc;Seii
fi tr c;ire
-J L i It
J t2l =V4
is 99
_J _thanoi 1001;,
Education/Relig. 5). Industrial 6. Commercial 7_ Mining
_i Cileseu'\'eg.OH
Blend
J ' getable Oil 100 /o
�i'teati<<e Oil
t/\ stc 00
• Mineral Oil no PCBs
J Mineral Oil -PCBs
J Other Petroleum
Products
Page o of 2

Notification of Discharge Report
Appendix A
Report Foruriats
IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected? 1. Yes NL 33l)nkro�n Number of Y"Ja° r Sup pl `vVQft� stA +�
-- - - -- ---- -- -- - --- -
t>t o ater upp y Wells Contaminated: (lnclud. Users PJarnes, t1 dresses and Phone Nun.�ers. Aftach addJtr(,ral sheet if oe<;essary)
1
2.
3.
PARTY RESPONSIBLE FOR RELEASE
(if the, source of the ratease is not an AST sysfetrr or ,' 7 is an AST S.isfen. and there is a resr urs,iale paay othe tharr ti, AS ` s, stem mvn ,ri oneratrc! I
---- -^ — _L Address
� 1 cp� . Number
ame at Pets Company p ��
I
Clty ?Late pp �' Code 1 L
AST SYSTEM OWNER(ifthe source of the release is an AST system}
AST w der ,Q pan % Aac r*e-ss �+ - -
�»>" ( to 1""" .t �ltd i>titE'c°► �°i^c�(i _ � -��h/ l _ Jor Still e- CGS
City State i It code "- —
A t� p 1 E!F r phone Number
-- -- -
AST SYSTEM'. GPEPATOR(if the source o, trie release is-
ST OperatoriCom/ipany / j
t�l_�5i-� ,✓ � � l Zi Y'L' %'l d��
� F
city Co. e I e!ephune Nurndbet
LANDOWNER AT LOCATION OF INCIDENT
Landowner - _. __ -- ---- -----
City tat o�
et & zP _
Draw Sketch of area of ]]Provide Ma (shove q inc:uent site location of r r�� s( ,r,�o rr, ,o ; oao ; tterst�;�t�cra. r;o?e,r_t:at
r� It Art:r�l? sketch it tnap roform.,
_- - Give Directions to Incident Site Artach L-iina lions to loan if nece S "'
re�yi �-7y %kE cx'if�� c�o Cets�c*h ►�w� -13 (gp'.rvx. � 7r,+,�►cs�'
!!�sfe, )S tom, ttk_ Ief f just i,� I��si✓✓eIa
Person Reporting Inc.ide Comer any /r e z're {%ti m-r
Title „ tg1- t, dzr 9V J l Y��_. ✓ F - - - - r l '
Sra c � Address UST Form 62," 4/10)1 }7C 0'
Definitions of Sources
. 'I (lank) rncat the tat ,..e I tr store Fnod'­i
t`;'1 Piping means the pipin - and on,11 1ol, a ,ling fi _'nm the :;Ink a
AS IAspenser. „tcltdc the, ie <tec a tc ,u, Lace nnvi
AST IX-fivery Problem: idenni cs ref _ se ,Y n: o'celulTod .,t. „t; rn K,ua_, jeliter tee the rrt,=_
O'iR Vehlcic fank, means the tark is used u, :,t(,rn )roducs n' t :.C, the 1_�ac cehtric
0IR Bulk hansport Vank means Li 1-amk tint ,s u, •d t'_, har .n..
RR :bulk I`rxtsport Twik- treat a tank that is a ee! t, It pi�.,.t t f in hc- 1,
Ilanslonuer means eie�tncal tntnainnter
Other: sexes as thr »pion tc, u e v.hen the release , ,t we i, k hug, O c - a0t
Unknortt: identifies rc!e.ttie, fcqr tct i.h tIu ce ha t t `),.,Cl. icten uxd
Definitions of (:fuses
S•>iil(Accidetuai) us4ih e_t,.:,celncns,spt,lccti_�:,u:d ,a ,�ep> cn;l.eho di"" m..icd
Spill (lntentiexre!i use thus cause shcn •anll , xur. r,en:i��n,ii. r' _ -ntcni:0flul l.irul,tn_
i-'otrosion use u�hert a rtctat T� nk, }>t nr�. �_�r i,.vr urtn .ertt�iru t ie"ease lt: t::, i , n,,
Ph,sical or kle;:hanical Darnaer use 1131 uli t l _; ,et h e :_d „ 1cehar,�e e rent .
l:gtnpnunt Iti1IUrC uscvfivn.1 t, "!,rpni.:nt �.�,_.:e _,,,er_na.i
AS T (A-ertili use when at net ul e _ Is tot c rt In Ite ij �> a e icn Li L t ,.
ASIC ht,taliatfun l'mh!em ucv.hen th,_ p ,-tut, „nectncd ,p�e,.:,al� x.ut c ,u.��` ' ,�: en; « , r�u rc
Other use this option vahea flit cause i knontt..w' dee- n,rt Gt tutu c,n, 1 t:tw p,t edt„ g ca c
t nknovn. use Gvhett the Cause t`_ye not beet; J !Tnmed -
Guidance: Ownership and Operator IVpe
Ucwtw,h,It Select the cate 'gon cciich de.:e:rt17—..t'.ter, r,7e A' i .astern. bulk tans} ' i ?a, n :uac r,etta,e "ounce
t;)Cr820I i- I Su!el'1 t�ec CtttC�i� e l,a!l'i, Qt�6:i;.lS ..c 6ISe aln.;; i[11�h.eil:I-wnli
�"k- 1,3,-
ge2of2

Beverly, Trudy
From: tom Bolyard <[e-mail]>
Sent: Wednesday, March 27, 2019 4:23 PM
To: Beverly, Trudy
Subject: [External] AST Discharge Notification Form
Attachments: Scan0560.pdf
I email. Do not click links or open attachments unless you verify. Send all suspicious email as an
[e-mail]
Trudy:
I've attached the Notification form we discussed earlier today. We will proceed with the soil
excavation/sampling beneath the AST and then I will submit an Initial Assessment Report to you in accordance
with the guidelines. Let me know if you have any questions.
Thanks,
Tom Bolyard, PG
Enviro-Pro, PC
Sent from Mail for Windows 10