MO-88768_91562_CA_UST-62_20180426_24-Hour Notification of Discharge Form

UST-62 24-Hour Notification of Discharge Form
For Non -UST This form should be completed and submitted to the UST Section's regional office following a known or suspected release of
Releases of petroleum from a source other than an underground storage tank. This form is required to be submitted within 24 hours of
discovery of a known or suspected petroleum release
Petroleum in NC
(DWM USE ONLY)
Suspected Contamination? (Y/N) _
Release discovered
Incident # Priority Rank (H,I,L,U)
Confirmed GW Contamination? (Y/N) N
(time/date):
Received (time/date)
Confirmed Soil Contamination ?(Y/N) y_
41�a l l Of) hours
Received by Region
Samples taken?(Y/N) m Free product? (Y/N) _N_
Reported by (circle one): Phone, Fax or Report
If Yes(free product), state greatest thickness: feet
INCIDENT DESCRIPTION
Incident Name: Best - 185 N Exit 58 Incident
Address (street number/name):185 N @ Exit 58 County: Cabarrus
City/Town: Concord
Zip Code: 27310
Regional Office (circle one): Ashe le Mooresville. ayetteville,
Raleigh, Washington, Wilmington, ins on a em
Latitude (decimal ciegrees): 34.9445097 Longitude (deconal degrees) :.80.612187 :
Obtained by:
❑ GPS
Describe suspected or confirmed release (nature of release, timeldate of release, quantity of release. amount of free
nmrlrrrtl
This incident was a single -vehicle tractor trailer collision, The estimated quantity of the release was approximately 50
❑ Electronic topographic map
gallons. The release impacted a roadside and unpaved roadway shoulder. Free -product was recovered and the
❑✓ Address
release has been contained.
GIS matching
❑ Other
soil removed, confirmation sampling):
❑ Unknown
Soil excavation and post -excavation sampling are pending.
Describe location:
Roadway
Describe impacted receptors:
Roadside drainage ditch
HOW RELEASE WAS DISCOVERED `Release Code)
(Check one)
Observation of Release at Occurrence ❑ Water Supply Well Contamination
8 Visual or Olfactory Evidence ❑ Surface Water Contamination
❑ Soil Contamination ❑ Other (specify)
❑ Groundwater Contamination
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 petroleum product
source) cause) type released)
❑ AST (tank) ❑ Spill (Accidental) Q Petroleum � Gasoline/ Diesel/ ❑ Diesel/Veg. Oil
AST Piping/ Dispenser ❑ Spill (Intentional) ❑ Both Petroleum Kerosene Blend
❑ AST Delivery Problem ❑ Corrosion & Non -Petroleum ❑ Ell — E20 ❑ Vegetable Oil 100%
❑J OTR Vehicle Tank ❑Physical or Mechanical ❑ E21 — E84 ❑ Heating Oil
® OTR Bulk Transport Tank Damage Location ❑ E85 — E99 ❑ Waste Oil
❑ RR Bulk Transport Tank ❑ Equipment Failure (Check one) ❑ Ethanol 100% ❑ Mineral Oil -no
❑ Transformer ❑ AST Overfill ❑ PCBs Facility
[] Mineral Oil -PCBs
❑ Unknown ❑ AST Installation Problem
❑ Residence ❑
❑ Other ❑ Unknown Other Petroleum
❑✓ Highway/Road Products
❑ Other
❑ Railway
Definitions presented on reverse Definitions presented on reverse
❑ Other
Ownership
1, Municipal 2. Military 3. Unknown 4. Private 5. Federal 6. County 7. State
Operation Type APR 2 6 2018
1. Public Service 2. Agricultural 3. Residential 4, Education/Relig. 5. Industrial 6. Cammercial . Mining
Guidance presented on reverse
UST Form 62 (04/10) NQ `� Aa,e 1 or 2
p

IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected?
1. Yes 2. No 3. Unknown Number of Water Supply Wells Affected
List of Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
1.
2.
3.
PARTY RESPONSIBLE FOR RELEASE
(if the source of the release is not an AST system or if it is an AST system and there is a responsible party other than the AST system ownerl operator)
Name of Person/Company
Address
BEST Logistics Group
P.O. Box 336
City
State
Zip Cade
Telephone Number
Kernersville
NC
27285
877-214-4450
AST SYSTEM OWNER (if the source of the release is an AST system)
AST Owner/Company
Address
Same
City
State
Zip Code
Telephone Number
AST SYSTEM OPERATOR (if the source of the release is an AST system)
UST Operator/Company
Address
Same
City
State
Zip Code
Telephone Number
LANDOWNER AT LOCATION OF INCIDENT
Landowner
Address
NCDOT - Division 10
716 W. main Street
City
State
Zip Code Telepphone Number
Albemarle
NC
28001 704-982-0101
Draw Sketch of Area or Provide Map (showing incident site, location of release, two majorroad intersections, potential
receptors)
Attach sketch or map to form.
Give Directions to Incident Site Attach directions to form if necessary,
see attached
Person Reporting Incident gill Frederick
Company Highlands Environmental Solutions, Inc.
Telephone Number 919-848-3155
Title Senior Environmental Scientist
Address 8410-D Falls of Neuse Road; Raleigh, NC 27615
Date 04/26/2018
UST Form 62 (04/10) rage 2 of e
Definitions of Sources
AST ('Tank) means the tank is used to store product
AST Piping: means the piping and connectors running from the tank to the dispenser or other end -use equipment
AST Dispenser. includes the dispenser and the equipment used to connect the dispenser to the piping
AST Delivery, Problem: identifies releases that occurred during product delivery to the tank
OTR Vehicle Tank. means the tank is used to store product to fuel an over the road vehicle
O"I'R Bulk Transport "Tank means a tank that is used to transport product in bulk over the road (by truck)
RR :bulk Transport Tank. means a tank that is used to transport product in bulk by train
Transformer: means electrical transfionner
Other serves as the option to use when the release source is known but does not fit into one of the preceding categories
Unknown. identifies releases tir which the sotuce has not been determined
Definitions of Causes
Spill (Accidental) use this cause when a spill occurs accidentall}(e.g., when the dehi cry hose is disconnected ftom a fill pipe)
Spill (Intentional): use this cause when a spill occurs intentionally (e g._ intentional dumping or breakage)
Corrosion: use when a meial tank_ piping or other component has a release due to corrosion
Physical or Mechanical Damageuse for all types of physical or mechanical damage, except corrosion
Equipment failure use when a release occurs due to equipment taiiure other than corrosion or physical or mechanical damage
AST Overfill: use when an overfill occurs over may occur fi'otn the fill pipe at the tank or when the nozzle fails to shut off at the dispenser)
AS']" Installation Problem. use when the problem is determined to have occurred specifically because the AST system was not installed properly
Other use this option when the cause is known but does not fit into one of the preceding categories
Unknown. use when the cause has not been determined
Guidance: Ownership and Operator Type
Ownership, select the category which describes owner of the AS system, bulk transport tank, or other release source
Operator Type select the category which describes the operation in which owner uses the AS'T system, bulk transport tank, or other release source

Approximate Scale
0 1000 2000
Feet N
Site Location Diagram
Base diagram from Google Maps.
Drawing /Project Name
Best Logistics Group Diesel Fuel Release Incident
Highlands Concord NC
Client
Environmental BEST Logistics Group
Project # DB I PM Fig.
Solutions, Inc. 429003 BF BF
Scale Date PG I PE
���"� As Shown April 2018 JB