MO-9472_40914_CA_UST-61_20190401_24-Hour Release and UST Leak Reporting Form

For Releases This form should be completed and tutirnifted to the UST Section's regional office mllowtng a krreeal or suspected release from
an underground storage tank (UST) eyetem- This form is required to be submitted vethln 24 boon of discovery of a known or
In NC
suspected release
Suspected Contamination? (YIN) Facility 10 Number 4v A
Confirmed GW Contamination? Data leek Dlermvered
(YIN)
Confirmed Soil Contamination ?(YIN) Gomm/Non-Commardal? AJo"
Samples Teken?(Y/N) RepfNon+egulated? Noti
Free Product? (YIN) _&L If Yes, State Greatest
Thickness AJIA
INCIDENT DESCRIPTION
Incident Name: I11+ IAArd'
?[Ace-
address it z� H0.1d'e
Q�u [
1
county Mlrcklt"
Ciry/Town: f'p��
ZIP Gode: ^Q
d.0 �o �'
Regional Once (cirde core): Asheville, s nFayetteville,
Raleigh, Washington. Wilmington. Wlnsto
Latitude(swami mgrwe): 3$', ],►11 �` Longitude(memai degees):—$Q.8RDO
Obtained by:
GPS
Briefly describe suspected or confirmed release: (alluding bull not limited to: nature of releture, data of rawass, 8moun—t
ofra amount of free Product present-andmovary
i]LJ;
aNbrte InMal was acted ' a to re tore
S00 0A10 V\ 1 n O 6 \
"'C
❑ Topographic map
S(W
%"
AkGISAddraeamatching
❑ Omer
❑ Unknown
Describe location:
aA&L 6 A S.
r sk &AD c7
Peso
HOW RELEASE WAS DISCOVERED (Reeves Coda)
(Check one)
❑ Release Detection Equipment or
Methods ❑ VlsualOdor ❑ Groundxater Contamination
During UST CloauraAamoval
❑ Water In Tank ❑ Surface Water Contamination
❑ Property Transfer
Q Water Supply Well Contamination ❑ Other (specify)
SOURCE OF CONTAMINATION
Source of Release
Cauea of Rolease Tyne of Release Product Type Released
(Check one to indicate primary
(Check one to Indicate primary (Check one) (Check one fo Indicate primary Product type
source)
cause) m/eased)
39 Tank
❑ Split Patrotaurn ❑ Gasoline/ Diesel ❑ DlaselVeg. ()if
❑ piping
Kerosene Blend
CI Overfill ❑ Non -Petroleum Heating Oil ❑ Vegetable Oil 100%
Dispenser
Corrosion Q1Both [] Otter Patroleum ❑ Etg_E20
❑ Submersible Turbine Pump
❑ Physical or Mechanical Products ❑
❑ E21 - E84
❑ Delivery Probem
Damage Metals
❑ Install Problem (Chheea w) ❑ Other Inorgantic, ❑ E85- EW
❑ Otter
❑ Other Organics ❑ Etranol 100%
❑ Unknown
Ll Other U Facility
Q Unknovm 19 Residence ❑ E01- E00
D®Mldons rented on reverse
peRnfspna tad on reverse - ❑ Other
QiliM
1, Munlclpeal 2. Military 3. Unknown VISO 6. Federal 6. County 7. State
oplawon Twine
t. Public Service 2. Agnounural
3Q!VeDW 4. Edumtion/Relig. 6. Industrial 6. Commercial 7. Mining
UST Form 61 (02108)
Papa 1 of 2
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IMPACT ON DRINKING WATER SUPPLIES
water Supply Wells Affected?
1. Yes 2. No 3. own
Number of Water Supply Wells Affected N/4
Water Supply Wells Contaminated:
(include Users Names, Addresses and Phone Numbers. Attach additional sheet If necessary)
NIA
2.
3.
UST SYSTEM OWNER
UST Owner C mpany
ma e&'.1
/ a ii-A M
Point of Cony)
Z—Ac k
A dress t�.�F/ ��-fj
Or �, 66 �
[/c .t i
o 1 1
City
CA
State 1
,v)C—
Zip Coders rr� Telephone Number
1t t�ro tP� 7'VT' V—r /1p
UST SYSTEM OPERATOR
UST Operator/Company
Address
City
Slate
Lip Code
Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
Pappas Fenk
owp_m L-c
Address
441�7- Sharon Qol. S
.sad
City
Gha r( e
State
NC_
Zip Code
a$ a- I t)
Telephone Number
_70 00.3 3
Draw Sketch of Area (showing two major road intersections) or Attach Map
tlKlm
%da"Ak, ANe-
Person Reporting Incident
Company &,e=wee CoraW, 'ram ,
Telephone Number
Title KQ;Address
SOQ
Date _ Vr
UST Form 61 (02M) Cka'7'0-ga //JC r2 81 6 1 Page 2 of 2
Definitions of Sources �'f
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 oguipmcm (Vent, vapor recovery, or fill
lines am 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 Partin (STP) Area includes the submersible turbine pump head (typically located in the tank sump), the line Teak detector, and the piping that
connects the submersible turbine pump to the tank
])*livery 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 Dot 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 spin occurs (0.g-, wbcn the delivery hose is disconnected from the tank fill pipe or when the not le is removed from the dispctisn-)
Overfill: use when an overGn Occurs (a-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 Dsmagc: mge for all types ofphysical or mechanical damage, except corrosion (e.g„ puncture of tank or piping, loose fittings, broken
components, and components that have chanced 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
.i.
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Beverly, Trudy
From: Beverly, Trudy
Sent: Monday, April 8, 2019 10:50 AM
To: Elledge, Lisa H
Subject: RE: fax attached
It's mine. Thanks so much for passing it along.
Have a great day,
Trudy
D Ek4;Nor 1ti Cnracx INA
Department of Environmental Duality
Tru& Bvvd, Lam.
Nor& C. ika Dq=ftmn2 afEwimmutd Qv ,
416T Seek4 lWomilk Faoamd Offin
M 25.K-210 pm*
ahr
Email correspondence to and from this address is subiect 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: h!Ws:Hdeq.nc.,gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: hllps:Hdeq.nc.gov/about/divisions/waste-management/ust/ast-
program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
https://deq.nc.gov/about/divisions/waste-management/waste-management-rules-data/waste-mane eg ment- ig s maps
File Review Procedures:
https:Hdeq.nc. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
hltps:Hedocs.deq.nc.aov/WasteManagement/Search.asp
Document Submittal St UST File Names for Laserfiche Policies:
httDs:Hfiles.nc. izov/ncdea/Waste%20Manaizement/DWM/UST/Corrective%20Action/Electronic%20Document%20Submittal
%20Memo%20Update.pdf
httt)s://files.nc. eov/ncdea/Waste%20Manaeement/DWMIUST/Corrective%20Action/UST%20file%20names%20for%20Las
erfiche.docx
From: Elledge, Lisa H
Sent: Monday, April 8, 2019 10:45 AM
To: Beverly, Trudy <[e-mail]>
Subject: fax attached
I think this looks like it would be yours — if not, could you please forward to the appropriate person? Thanks!

Lisa Ell edo,
Adminisirmiiu Asszxiuir, DEALS
North Carolina Depalment of Environment Quality
mooresville Regional Office
704.23 5.2114 (Officc)
[e-mail]
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