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HomeMy WebLinkAboutMO-9370_40824_CA_UST-61_20180412_24-Hour Release and UST Leak Reporting FormUST-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