MO-9475_40916_CA_UST-61_20190617_24-Hour Release and UST Leak Reporting Form

UST-61
24-Hour Release and UST Leak Reporting Form.
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)
Facility ID Number
Incident # Risk (H,I,L,U)
Confirmed GW Contamination? (Y/N)
Date Leak Discovered
Received On Received By
Confirmed Soil Contamination ?(Y/N)
Comm/Non-Commercial?
Reported by (circle one): Phone, Fax or Report
Samples Taken?(Y/N)
Reg/Non-regulated?
Region
Free Product? (Y/N) If Yes, State Greatest
Thickness
INCIDENT DESCRIPTION
Incident Name:
Address:
County:
Regional Office (circle one): Asheville, Mooresville, Fayetteville,
City/Town:
Zip Code:
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees):
Longitude (decimal degrees) :
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
❑ Unknown
Describe location:
HOW RELEASE WAS DISCOVERED (Release code)
(Check one)
❑Release Detection 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 primary source)
(Check primary cause) (Check one) (Check primary product type released)
❑ Tank
❑ Spill ❑ Petroleum ❑ Gasoline/ Diesel/ ❑ Diesel/Veg. Oil
❑ Piping
❑ Overfill ❑ Non -Petroleum Kerosene Blend
❑ Dispenser
❑Heating Oil ❑ Vegetable Oil 100%
Corrosion Both
❑❑
❑ Other Petroleum ❑ E10 - E20
❑ Submersible Turbine Pump
❑Physical/Mechanical
❑ Delivery Problem
Location Products
Damage ❑ E21 - E84
(Check one) Metals
❑
❑ Install Problem ❑ E85 - E99
❑ Spill Bucket
❑ Other Inorganics
❑ Other [-]Facility ❑Ethanol 100%
❑ Other
❑ Other Organics
❑ Unknown ❑Residence ❑ E01 - E09
❑ Unknown
❑Other
Definitions presented on reverse
Definitions presented on reverse
Ownership
1. Municipal 2. Military 3. Unknown
4. Private 5. Federal 6. County 7. State
Operation Type
1. Public Service 2. Agricultural 3.
Residential 4. Education/Relig. 5. Industrial 6. Commercial 7. Mining
UST Form 61 (02/19) 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
Water Supply Wells Contaminated:
1.
2.
3.
(Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
UST Owner/Company
UST SYSTEM OWNER
Point of Contact
Address
City
State
Zip Code
Telephone Number
UST SYSTEM OPERATOR
UST Operator/Company
Address
City
State
Zip Code
Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
Address
City
State
Zip Code
Telephone Number
Draw Sketch of Area (showing two major road intersections) or Attach Map
Person Reporting Incident
Company
Telephone Number
Title
Address
Date
UST Form 61 (02/19)
Page 2 of 2
Definitions of Sources
Tank: means the tank that stores the product and is part 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 dispenser 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 to the tank. (Typical causes associated with this source are spills and overfills.)
Other: serves as the option to use when the release source is known but does not fit into one of the preceding categories (e.g., for releases from vent lines, vapor
recovery lines, and fill lines)
Unknown: identifies releases for which the source has not been determined
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 nozzle is removed 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

LEGEND
UNDERGROUND NATURAL GAS LINE
ss
UNDERGROUND STORM SEWER LINE
— w w —
UNDERGROUND WATER LINE
E
OVERHEAD ELECTRIC LINE
— — — — — — — — — UNDERGROUND STORAGE TANK
0
FILL PORT
FUEL DISPENSER
•
VAPOR PORT
VENT
VENT LINES FOR UST
TYPE II MONITORING WELL
f
SOIL SAMPLE LOCATION
5030/
3550/
Analytical Method 4
EPA Method 8260B
8015D
8015C
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N
QJ
N
W
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W
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RAL(mg/kg)
50
100
NE
NE
NE
NE
Soil to Water MCC (mg/kg)
NE
NE
0.0056
4.3
4.9
4.6
Residential SCLs (mg/kg)
NE
NE
18
1,200
1,560
3,129
SB-1 (2.5')
06/04/19
2.S
2,590
327
7.40
196
81.3
641
SB-2(2.5')
06/04/19
2.5
124
298
1.59
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<0.074
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MKDK
FOOD MART
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0 15 30 60 SOIL QUALITY MAP (06/04/19)
MKDK Food Mart 2500 South Main Street
Incident No. N/A Kannapolis, Cabarrus County,
( IN FEET) GRI Project No. 4760 NC
Geo%g/co/ Resources, Inc. 1 inch = 30 ft Date: 06/16/19 Drawn by. DTH I Figure: 3

Beverly, Trudy
From: Beverly, Trudy
Sent: Wednesday, June 19, 2019 11:51 AM
To: Corey Buchanan
Subject: RE: [External] UST-61 form and map for the MKDK Food Mart site.
Corey,
Site Check Requirements can be found in the Guidelines for Site Checks, Tank Closure and Initial Response at the
following link https://deg.nc.gov/about/divisions/waste-management/ust/guidance-documents.
When conducting a site check per Title 15A NCAC 2N .0703 and .0704, the procedures below must be
included:
"If any components intersect the water table, are installed on bedrock, or are surrounded by gravel fill, or
where required by the UST Section based on other site -specific data, a permanent monitoring well,
constructed according to Title 15A NCAC 2C, Well Construction Standards, must be installed as close as
possible to and within 5 feet of the (part of the) UST system with the (suspected) release in a downgradient
direction, and a groundwater sample must be collected and analyzed as specified in Tables 4 and 8."
Trudy
, ow, a emm DE
_ r4�
NORTH CAROLINA \\
nepartment of Environmental Quality I.-S
T i*-, L.G.
LEI q l s�1 Rle l a
C" 235.2182 (0
WrinodalrM
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
Office Mailing Address:
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Branch's Underground Storage Tanks Website Address: hlt2s:Hdeq.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: https:Hdeq.nc.gov/about/divisions/waste-management/ust/ast-
rp o�rain
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
hlt2s:Hdeq.nc.aov/about/divisions/waste-management/waste-management-rules-data/waste-mana eg ment- ig s-maps
File Review Procedures:
https://deq.nc. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
https:Hedocs.deq.nc.izov/WasteManagement/Search.asp
Document Submittal & UST File Names for Laserfiche Policies:
httns://files.nc. eov/ncdea/Waste%2OManaeement/DWMIUST/Corrective%2OAction/Electronic%2ODocument%2OSubmittal
%20Memo%20Memo%2OUpdatepddf
httDs://files.nc.gov/ncdea/Waste%2OManauement/DWM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLas
erfiche.docx

From: Beverly, Trudy
Sent: Tuesday, June 18, 2019 1:30 PM
To: Graham, Dan <[e-mail]>
Cc: Corey Buchanan <[e-mail]>
Subject: RE: [External] UST-61 form and map for the MKDK Food Mart site.
Dan — Yes, this one is in Cabarrus County. Thanks for passing the UST-61 along.
Hey Corey — I handle Cabarrus County sites. Future communications related to this site should be sent to my
attention.
Thank you,
Trudy
D
�.Ek1;
NORTri CAROLINA
Department of Environmental quality
TIC , Lam.
#1111 40. ayJ-4-A*MzWMA4W§M
Nenh Codba Ewpauils d
arslsea ama
(7" 23S,21i2 (OR*
1rW.B odIIIR�01�
Email correspondence to arKJ from this address is subject to the
North Carolina Public fWswrds Law and may be disclosed to third parties.
Office Mailing Address:
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Branch's Underground Storage Tanks Website Address: https:Hdeq.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: https:Hdeq.nc.aov/about/divisions/waste-management/ust/ast-
rp og
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
https://deq.nc.gov/about/divisions/waste-management/waste-management-rules-data/waste-mana eg merit- ig's-maps
File Review Procedures:
hops://deg.nc. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
https://edocs.deq.nc.gov/WasteManagement/Search.asp
Document Submittal & UST File Names for Laserfiche Policies:
hops://files.nc.gov/ncdeq/Waste%20Mana,gement/DWM/ JST/Corrective%2OAction/Electronic%2ODocument%2OSubmittal
%20Memo%20Update.pdf
https://files.nc.gov/ncdeq/Waste%20Mana,gement/DWM/ JST/Corrective%2OAction/UST%20file%20names%20for%2OLas
erfiche.docx
From: Graham, Dan
Sent: Tuesday, June 18, 2019 1:21 PM
To: Beverly, Trudy <[e-mail]>
Cc: Corey Buchanan <[e-mail]>
Subject: FW: [External] UST-61 form and map for the MKDK Food Mart site.

Trudy,
I think this is yours
From: Corey Buchanan<[e-mail]>
Sent: Monday, June 17, 2019 11:19 AM
To: Taraban, Ron <[e-mail]>
Cc: Graham, Dan <[e-mail]>; [e-mail]
Subject: [External] UST-61 form and map for the MKDK Food Mart site.
External email. Do not click lin as an
attachment to [e-mail]
Hello Mr. Taraban and Mr. Graham,
Following a site check, a release was confirmed. Please find attached the UST-61 form and map for the
MKDK Food Mart site.
Per the responsible party, please issue a directive to confirm the next required scope of work for this site.
Also one test well is located behind the UST basin that had 2" or less of water during site activities and
another test well on the other side of the UST basin that was not checked. Can those wells be used if
needed?
Thanks
Best Regards,
Corey N. Buchanan, P.G.
Project Manager
Geological Resources, Inc.
3502 Hayes Road

Monroe, NC 28110
Main [phone] Cell [phone] Fax [phone]
www.geologicaIresourcesinc.com
NCPCM 2015 Vendor of the Year Recipient
Business North Carolina Magazine 2015 Small Business of the Year Runner-up Recipient