MO-9370_40824_CA_UST-61_20180412_24-Hour Release and UST Leak Reporting Form

UST-61
24-Hour Release and UST Look, Re
I porting 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) 7
Facility ID Number
Incident # Risk (H,I,L,U)
Confirmed GW Contamination? (Y/N) 1
Date Leak Discovered
Received On Received By
Confirmed Soil Contamination ?(Y/N) N
Comm/Non-Commercial?
Reported by (circle one): Phone, Fax or Report
Samples Taken?(Y/N) , i'
Reg/Non-regulated? Nor -Reg
Region
Free Product? (Y/N) L_ If Yes, State Greatest
Thickness
INCIDENT DESCRIPTION
Incident Name: CN Jenkins Memorial Presbyterian Church
Address: 1421 Statesville Avenue _FCounty:
Me.­..k
City/Town: Charlotte
28206
Regional Office (circle one): Asheville,<IT6ores
1�� Fayetteville,
Raleigh, Washington, Wilmington, Winston-Salem
3 S . .: 4 2
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:
­
!pz-l_'_ 6, 2,",13, sn-aIll �,.v,cun- .,-f p�rod_lct v: a is -i�d n
HOW RELEASE WAS DISCOVERED (Release Code)
(Check one)
J Release Detection Equipment or Methods F-1 Visual/Odor F-11 Groundwater contamination
1:3 During UST Closure/Removal L1 water in Tank F❑I surface water contamination
❑ Property Transfer J water Supply Well Contamination ❑ Other (specify)
SOURCE OF CONTAMINATION
Source of Release Cause of Release Type of Release Product Type Released
(Check one to indicate primary (Check one to indicate primary (Check one) (Check one to indicate primary product type
source) cause) released)
❑ Tank J spill ❑ Petroleum LJ Gasoline/ Diesel/ J Diesel/Veg, Oil
PqKerosene Blend
LJ Piping J Overfill Ll Non -Petroleum Heating J
Oil Vegetable Oil 100%
Ll Dispenser LJ Corrosion LJ Both L) Other Petroleum J E10 — E20
❑ Submersible Turbine Pump L) Physical or Mechanical Products LJ E21
❑ Delivery Problem Damage Location LJ Metals — E84
Install Problem (Check one) Lj Other Inorganics LJ E85 — E99
Other Organics J Ethanol 100%
L) Other J Other
❑ 71
Facility
F-1 unknown El unknown F-11 Residence J E01 — E09
Definitions presented on reverse Definitions presented on reverse LJ Other
Ownership
1. Municipal 2. Military 3. Unknown 4. <Z!ova 5. Federal 6. County 7. State
Operation Type
1. Public Service 2, Agricultural 3. Residential 4 5. Industrial 6. Commercial 7. Mining
u6 I Form bi (uz1u8) Page I 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: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
1.
2.
3.
UST SYSTEM OWNER
UST Owner/Company
>'N ,Jenkins Memorial Presbyterian Church
Point of Contact
Address
Mr, Sarn Bar-ber
1421 Statesville Avenue
City
State
Zip Code
Telephone Number
Charlotte
NC
28206
(980) 214-61€0
UST SYSTEM OPERATOR
Same As Above
UST Operator/Company
Address
City
State
Zip Code
Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Sa€ate as Above
Landowner
Address
City
State
Zip Code
Telephone Number
Draw Sketch of Area (showing two major road intersections) or Attach Map
Sep: attached
Person Reporting Incident Matt Miller
Company Ames Sorter l•"11�r:eler
Telephone Number (r )�t)3 r_ 52,
Title Se:7 yr Sraierttist
Address 280�1 York Wont Road, Suite 100. Chado te. NC 28208
Date �i 1� &
UST Form 61 (02/08)
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 till
lines are excluded.)
Dispenser includes the dispenser and the equipment used to connect the dispenser to the piping (e g„ a release tio€n 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 tine 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 detennined
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 frorn the till pipe at the tank or when the nozzle tails 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 whert a metal tank, piping, or other component has a release due to corrosion (t_g_ for steel. corrosion takes the fbrm oflust)
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., putttrt, regulated substances into monuorin; wells)
Unknown: use when the cause has not been determined