MO-9503_40940_CA_UST-61_20190930_24-Hour Release and UST Leak Reporting Form

UST-61
I
24-Hour Release and UST Leak Reporting Form.
For Releases This f
3rm should be completed and submitted to the UST Section's regional office following a known or suspected release from
an u
iderground 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 USEONLY)
Suspected Contamination? (YIN)
Facility ID Number
Incident # Risk (,I,L,U)
Confirmed GW Contamination? (YIN)
Date Leak Discovered
Received On Received
By
Confirmed Soil Contamination ?(Y/N)
Comm/Non-Commercial?
Reported by (circle one): Phor
e, Fax or Report
Samples Taken?(Y/N)
Reg/Non-regulated?
Region
Free Product? (YIN) If Yes, State Greatest
Thickness
INCIDENT DESCRIPTION
Incident Name:
j Ha69
xi'l,S
Address:
er
County:
City/Town: l
TZip Code:f
egional Office (circle one): Asheville, Moore e, Fayetteville,
[Raleigh,Washington, Wilmington, Winston-Salem
Latitude (decimal degrees)3S�
�. - Longitude (decmal degrees) :, S5, -
Obtained by:
❑
Briefly describe suspected or c
nfirmed relea e: (including but not limited to: nature of release, date of release, amount
of release amount of free product
resent and recoveryefforts, initial responses conducted, impacts to receptors)
GPS
❑Topographic map
❑GIS Address matching
❑ Other
❑ Unknown
Describe location:
2 l fit/
-�,.o : L jce g o zt 0'3 7-
r
tiVtt r6 Oe-t limn 4c,4e. l �. c
`fv
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 Tvpe Released
(Check primary source)
(Check primary cause) (Check one) (Check primary product type released)
Tank
Petroleum ❑ spill p ❑Gasoline/ Diesel/ ❑ DieselNeg. Oil
Piping
p g
Kerosene Blend
Overfill ❑Nop-Petroleum
❑ Dispenser
Corrosion ❑ Both Heating Oil ❑ Vegetable Oil 100%
❑ Submersible Turbine Pump❑
Physical/Mechanical ❑Other Petroleum ❑ E10 - E20
❑ Delivery Problem
Location Products
Damage (Check one) ❑ Metals E21 - E84
❑
❑ Spill Bucket
❑ Install Problem ❑ E85 - E99
❑ Other
❑ Other Inorganics
❑Other ❑Facility []Ethanol 100%
❑ Unknown
❑ Unknown Residence ❑ Other Organics ❑ E01 - E09
114
❑Other
Definitions resented on rever
Definitions presented on reverse
Ownership
1. Municipal 2. Military 3. Unknown
rivate 5. Federal 6. County 7. State
Operation Type
1. Public Service 2. Aghcultu
4. Education/Relig. 5. Industrial 6. Commercial 7. Mining
ral 3.Ei�o
uo i corm o f (Vzrry) I Page 1 of 2

Water Supply Wells Affected?
Number of Water Supply WellE
IMPACT ON DRINKING WATER SUPPLIES
1. Yes 2. No 3. Unkno
Affected
Water Supply Wells Contamin
1.
2.
3.
ted: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
UST Owner/Company
UST SYSTEM OWNER
Point of Contact
r 1 11
Address 01 *
City
State
/UG
Zip Code
ZgZiS-
Telephone Number
UST SYSTEM OPERATOR
UST Operator/Company
Address
City
FState
Zip Code
Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner F
��a
�ern"n e a
Address
`1: i o) t W6 L
City
(kW64 e
State
I NC
Zip Code
ZSz i 11
Telephone Number
Draw Sketch
of Area (showing two major road intersections) or Attach Map
erson Reporting Incident
LT
_`' M�Sa�
Company "� 11W.,Pson ko)0
Telephone Number 7oq-�-63'6Eitle
Address L JJ " IU �e5� '�A','J ' �C
Date %C> iy
UST Form 61 (02/19) 1Page 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 ind 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 vhicb the source has not been determined
Definitions of Causes
Spill: use this cause when a ill 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 cK curs (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, i isc for all types of physical or mechanical damage, except corrosion (c.g., puncture of tank ur piping, luuse 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 th e problem is determined to have occurred specifically because the UST system was not installed properly
Other: use this option when a 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 ho not been determined

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Beverly, Trudy
From: Philip Thompson <[e-mail]>
Sent: Monday, September 30, 2019 10:54 AM
To: Beverly, Trudy
Subject: [External] ust 61
Attachments: scan0008.pdf
External email. Do not click links or open attachments unless you verify. Send all suspicious email as an
attachment to [e-mail]
I filled out a new one here it is