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Home My WebLink AboutMO-9532_40967_CA_UST-61_20190313_24-Hour Release and UST Leak Reporting Form2 Hour gm a" and 03'1' • '"`r� ,� For Releases This form should be completed and submitted to the UST Section's regional office followinga 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 tY Risk (H,I,L,U) Confirmed GW Contamination? (Y/N) ��l/ _ Date L Dlsoov re _ _—_— Received On Received By Confirmed Soil Conlamina)ion ?(Y/N) Com on-Commercial_;� Reported by (cinde one): Phone, Fax or Report Samples Taken?(YIN) �_ -Co Reg on-regula e --------- Region Free Product? (Y/N) __&I_ If Yes, State Greatest Thickness 4-1 INCIDENT DESCRIPTION Incident Name: jam\ /y 1 � Address: L` r�'C County: fY\ I2iL Iy.. 1z' City/Town: C� �� Zip Code: �f �. Regional Office (circle one): Asheville, ooresville Fayetteville, Raleigh, Washington, Wilmington, Winston-Salem Lau tude{ded"degrees): Longitude (declmWdogreim) : 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 `'\ Z, v�� r O Y�� O� 1 ❑ GIS Address matching ` C►�\1 0-� ❑ Other U Unknown Dcscribe location: �p n HOW RELEASE WAt DISCOVERE (Release Code) 1w�t, .� ;N%'t , (Check one) ❑ Release Detection Equipment or Methods U Visual/Odor ❑ Groundwater Contamination During UST Closure/Removal ❑ Water in Tank ❑ Surface Water Contamination Property Transfer ❑ Water Supply Well Contamination ❑ Others cif SOURCE OF CONTAMINATION Source of Release Cause of Release Type of Release Product Tme Released (Check one to indicate primary (Check one to indicate primary (Check one) (Check one to indicate primary product type source) cause) released) Tank ❑ Spill petroleum ❑ Gasoline/ Diesel/ ❑ Diesel/Veg. Oil Kerosene Blend ❑ Piping ❑ Overfill U Non -Petroleum %Hoaling Oil U Vogetablo Qil 100% ❑ Dispenser Corrosion U Both ❑ Other Petroleum ❑ E 10 - E20 ❑ Submersible Turbine Pump ❑ Physical or Mechanical Products U E21 E84 - Damage Location ❑ Metals ❑ Delivery Problem ❑ Install Problem (Check one) ❑ Other Inorganics U E85 - E99 ❑ Other ❑ Other ❑ Other Organics ❑ Ethanol 100% ❑ Facility ❑ Unknown ❑ Unknown INLResidence ❑ E01 - E09 Definitions presented on reverse Definitions presented on reverse ❑ Other Ownershio 1. Municipal 2. Military 3. Unknown . Private 5. Federal 6. County 7. State Operation Type 1. Public Service 2. Agricultural 3. idential 4. Education/Relig. 5. industrial 6. Commercial 7. Mining UST Form 61 (02/08) Page 1 of 2 04N-� IMPACT ON DRINKING WATER SUPPLIES Water Supply Wells Affected? 1. Yes 2. No �Ukn Number of Water Supply Wells Affected ______________ Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary) 1. »> 2. 3. UST SYSTEM OWNER UST Owner/Company 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 <r �`�� State �, Zip Code Z�Z��, Telephone Number '7oq,17( L) Draw Sketch of Area (showing two major road intersections) or Attach Map Person Reporting Incident Company Telephone Number Title < 1\ '� to Address �t'J Date uS i rorm Cl timmu) r 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 subrrsible 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 pniduct 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 nuzzle 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 nionnoring wells) Unknown: use when the cause has not been determined Beverly, Trudy From: Beverly, Trudy Sent: Monday, March 25, 2019 9:26 AM To: 'Steve Hamilton' Cc: tim@cert-usa.com; 'Ryan Osborne'; dholden@carolina.rr.com Subject: RE: [External] 24 HR Notice Adams Property at 934 West Mallard Creek Church Rd. Received. Trudy Tr* . L.G. AEQ � ,� lity Quay L'ST Sedio4 III Ile Rgimd OIfee fm 211-3193 FC -nl Finail conespandence to and from this address is subject to the North Caroline Public Records Lew and may be disclosed to third ,oerties. 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: hLps://deq.nc.gov/about/divisions/waste-management/ust/ast- program INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES: hgps://deg.nc.gov/about/divisions/waste-management/waste-management-rules-data/waste-mana e,� ment ig s-maps File Review Procedures: hiips:Hdeq.nc. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche): hllps:Hedocs.deq.nc.gov/\VasteManagement/Search.aspx Document Submittal & UST File Names for Laserfiche Policies: httDs://files.nc. Gov/ncdea/Waste%2OManaiiement/DWM/UST/Corrective%2OAction/Electronic%2ODocument%2OSubmittal %20Memo%2OUpdate.pdf httDs:Hfiles.nc. eov/ncdea/Waste%2OManaeement/DWM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLas erfiche.docx From: Steve Hamilton[mailto:smhamilton@comporium.net] Sent: Monday, March 25, 2019 9:19 AM To: Beverly, Trudy <trudy.beverly@ncdenr.gov> Cc: tim@cert-usa.com; 'Ryan Osborne' <rro@inencoinc.com>; dholden@carolina.rr.com Subject: [External] 24 HR Notice Adams Property at 934 West Mallard Creek Church Rd. Vernal email. Do not click links or open attachments unless you verify. Send all suspicious email as an achment to report.spam@nc.gov Trudy Beverly NCDEQ Trudy, Attached please find the 24 HR Notice for Adams Property at 934 West Mallard Creek Church Rd. Charlotte, NC. Regards, Steve Steve Hamilton- Consultant C.E.R.T. Carolina Environmental Response Team PO Box 681016 Charlotte, NC 28216 704-309-4262 cell 877-505-6799 office � T t-,--_6- CONFIDENTIALITY NOTICE: This e-mail communication, including any attachments, may contain privileged or confidential information for specific individuals and is protected by law. If you are not the intended recipient(s), you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited and you should delete this message and its attachments from your computer without retaining any copies. If you have received this communication in error, please reply to the sender immediately. We appreciate your cooperation. Please consider the environment before printing this e-mail.