MO-9471_40913_CA_UST-61_20190401_24-Hour Release and UST Leak Reporting Form

This torn should be completed and submitted to the UST Section's regional office following a known or suspeced release from
For Releases
an underground storage tank (UST) system- This form Is mQulmd to be submitted within 24 hours of discovery of a known or
In NC suspected release
Contamination? (YIN) ), Facility ID Number N p
Confirmed OW Dontaminafion? (Y/N) IV Date Lesk Discovered ^
Confirmed Soil Contamins n ?(Y/N) Comm1wonCommerdal?
Samples Taken?(YIN) Y_ ReglNont Quleted?
IN=Suspected
Free Product? /N) AM- If Yes, State Greatest
Thlcknese
INC ENT DE IPTION
Incident Name: /a 8 6 reerl vt r C l
Address: S CGr[ a n, w ao C 111 County: M ec M'I
Regional OMca (circle one)' Asheville, e. Fa villa,
Zip Code: 21 zQ 4 Rplelph1,, Washington, W irninglon, Wlnsto m
Cipd7own: G` � r O ,e
p
Latitude (brdrael a.o ): 3 S. oZ li $ Longitude (decimal dea.) = — SO.
Obtained by:
❑ OPS
edgily describe suspected or confimmed release: (Including ouf not llmlsad to: nature of release, data of raleese, amount
obAs ass emounf of free produet present and reco aifons inidal re8 rises ukded f to recs tag
1 1�.4.0-' .{a..tik
❑Topographic map
:
i reS
GiS Address matching
$ Ob
❑other
Tesr�
20� "fly.
ri
❑ unknown
Describe location:
HOW RELEASE WAS DISCOVERED (Reiaa code)
(Check wma)
❑ Release Detection Equipment or Methods ❑ VisualfOdor ❑ Groundwater Contamination
During UST Closure/Ramoval ❑ Water In Tank ❑ Surface Water Contaminadon
ClProperty Transfer ❑ Water Supply Wall Contamination El Other (specify)
SOURCE OF CONTAMINATION
SOUrce_4f Release Cause of Rolease Tune of Release Product Type Released
(Check one to Inndicate primary (Check one to irdicarn primary (Check one) (Check one to inddmary product lypa
cause)
Tank ❑ Spill �. Petroleum ❑ Gasoline] Diesel/ ❑ D'ieselfV09 Oil
Bland
❑ Ovarfill ❑ NonrPetmleum Keene
❑ Piping � Heating Oil Q Vegetable OII 100%
❑ Dispenser ACorroslon ❑ Bohm ❑ Other Petrolaum ❑ E10—E20
❑ Submersible Turbine Pump ❑ Physical or Mechanical Products ❑ E21 — F84
❑
Damage Location Metals
❑ Delivery Problem ❑ Install Problem (Check one) Q Other Inorganics Q E85 — Egg
❑ Other ❑ Other Organics ❑ Ethanol 100%
❑ Unknown El❑ ❑ FadBy
�.Rasttlence ❑ E01 -- E00
Unkrawn
nkn
Defirwarrs Dreadnied I DeflNBvrs presented on reverse Q Other
1. Municipal 2. Military 3. Unknown ele!RD S. Federal S- County 7. Stele
Ooeretlon Tvob
1. Public Service 2. Agricultural 3�e 4. Education/Rellg. 5. Industrial 6. Commercial 7. Mining
t2
UST Form 81 (02108)
aget '.
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Water Supply Wells Affected? 1. yes
IMPACT ON DRINKING WATER SU
2. No 3. <n nown
Number of Water Supply Wells Affected
Water Supply wells Contaminated: (Include Users Names, Ad,
1, NIA
2.
UST
UST
of COIZ5
r__ Vi
NO
UST Form
and
additional
UST SYSTEM
OWNER
j �Ib N� � LL.
Address
l 131 NaR � � ►•� � (o-4
State Zip Code Telephone Number
1J� .2Q 11%d
UST SYSTEM OPERATOR
Address
Zip Code I Telephone
LANDOWNER AT LOCATION OF UST INCIDENT
s �� State
1 � Telephone Number
! Zip Code
ti
L10 Of —
Draw Sketch of Area (showing twopajor road intersections) or Attach Map
HAM06 1� P ( aver; ' ,`r e.
:b%.eee--
duC- R 81-
Telephone
Date
Page 2
Defuddons of Sources
Tank: means the tank that stores the product and is pan of the underground storage tanknsystem a dis enser or other cad -use equipment (V cat, vapor recovery, or fill
Piping: means the piping and connectors running from the tank or submersible turbine pump P
lines are excluded,) from components located above
Dispenser. includes the dispenser and the equipment used to connect the dispenser to the piping (e.g., a release from a suction pump or p
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 end overfills.)
Delivery Problem: identifies releases that occurred during product delivery to the tank_ (Typical causes associated with this are spillsva or
Other. serves as the option to use when the release %come is known but does not fit into one of the preceding catsgg
ories (e for releases from vent lines, p
recovery lines, and till lines)
Unknown: identifies releases for whicb the source has not been determined
Definitlons of Causes
Spill: use this cause when a spill occurs (c.g_ when the delivery hose is disconnected from the tank fill pipe or when the nozzle is removed from the dispenser
e fill pipe at the tank or when the nozzle fails to shut off at the dispenser)
Overfill: use when an Overfill Orcora (e.g-, overfills may occur from thbroken
Physical or Mechanical Damage: use for all types of physical or mechanical damage, except corrosion puncture o[ tank or piping, loose fittings,
components, and components that have changed dimension)
Canrosion:use when a metal tank, piping, or other component has a release due to corrosion (cg_, for steel, corrosion takes the form of rust)
Installation Problem: use when the problem is determined to have occurred specifically because
he U T system was
rC not
in installed
l substances into monitoring wells)
Other. use this option when the cause is known but doe' not fit into one of the preceding 6 g., putting
Unknown= use when the cause has not been determined
ZO'd ZS:60 6TOZ 8 .add TSOZSZSVOZ:XPJ

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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