MO-88774_91569_CA_UST-62_20200206_24-Hour Release Reporting Form

UST-61
24-Hour Release and UST Leak Reporting 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)
Incident # Risk (H,I,L,U)
Suspected Contamination? (Y/N)
Confirmed GW Contamination? (Y/N) N
Facility ID Number
Date Leak Discovered 2 • 6 • Zory
Received On Received By -
Reported by (circle one): Phone. Fax or Report
Confirmed Soil Contamination ?(Y/N) _/
Samples Taken?(Y/N) y
Comm/Non-Commercial?
Region
Free Product? (Y/N) y If Yes, State Greatest
Reg/Non-regulated?
Thickness 2 'NCR J'
INCIDENT DESCRIPTION
Incident Name:
t. 13 T!L u c k iiv' .
Address: i7 2 M 0 0 m7- PXaA,SFJ 1v y' AD
County:
CA $A1Z2uS
City?own: '
CbN O I
Zi Code:
p Code:,,,,,
Regional Office (circle one): Ashevill pores , Fayetteville,
Raleigh; Washington, Wilmington, Winston-Salem
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, tm acts to rece tors
❑ Topographic map
❑ GIS Address matching
❑ Other
❑ Unknown
Describe location:
O O X Vi /i i C 4,Q C C / u,.r rgucZL jZc
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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) Yvi�
SOURCE OF CONTAMINATION
Source of Release Cause of Release Type of Release Product Tvpe Released
(Check one to indicate primary (Check one to indicate primary (Check one) (Check one to indicate primary product type
source) cause) released)
�,.,
Tank ElL7/ Spill Petroleum �j Gasoline/ Diesel/ ❑
Diesel/Veg. Oil
Kerosene Blend
❑ Piping ❑ Overfill ❑ Non -Petroleum ❑
Heating Oil ❑ Vegetable Oil 100%
❑ Dispenser Corrosion ❑ Both ❑
Other Petroleum ❑ El0-E20
�❑.
�:1 ❑ Submersible Turbine Pump Physical or Mechanical Products
❑ Delivery Problem Damage Location ❑ Metals ❑ E21-E84
❑ Install Problem (Check one) ❑ Other Inorganics ElE85-E99
❑Other
❑ Other Organics ❑ Ethanol 100%
❑ Unknown ❑Other ❑I�'1-Facility
W
❑ Unknown Residence ❑ E01 - E09
Definitions presented on reverse Definitions presented on reverse ❑ Other
Ownership .--
1. Municipal 2. Military._Pny3. Unknown _ -5_Eederal6. County..7-. State —
Operation Type
1. Public Service 2. Agricultural 3. Residential 4. Education/Relig. 5. Industrial 6. Commercial 7. Mining
I ICT P. ,e F1 MIMI
Page 1 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
TrZuckr,yd-
Point of Contact
Address
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Bess
/moo Box /yi0
City
State
Zip Code
Telephone Number
ISO G k cu r 4 L
IV C
c2 R J 3 2?
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UST SYSTEM OPERATOR
UST Operator/Company
Address
City
State
Zip Code
Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
Address
.; sr„v t 5051-71-1 50R6 Me15'TEfc
(07) 7
City
State
Zip Code
Telephone Number
CoA/d!0
A/ C
aSoa
Draw Sketch of Area (showing two major road intersections) or Attach Map
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11,
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TRAd �101/
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Person Reporting Incident
Company
Telephone Number
Title
Address
Date
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 (Vem, 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 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 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 nozzle 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 monitoring wells)
Unknown: use when the cause has not been determined

North Carolina Emergency
Management
EM43 Reporting
EMAP
'�Acarditer�;.
Taken By:
Date/Time Reported:
Date/Time Occured:
DS -JB
2/6/2019 11:29:50 AM
2/6/2019 4:06:50 AM
Reported By:
Agency:
Phone:
Doug Steele
Cabarrus County EM
704-920-2143
County: Cabarrus
City: Concord
Area: 11
Street Address:
6777 Mount Pleasant Road S
ZIP Code: 28025
EVENT TYPE
Type:
HazMat
HAZMAT Event Type: Diesel Fuel
HAZMAT Class: Petroleum
HAZMAT Mode: Transportation
Event Description
Diesel Fuel spill as the result of a MVA. Cabarrus County EM and Georgeville FD responded to a MVA in front of
6777 Mt Pleasant Road S. Upon arrival found a tractor trailer that left the roadway and struck a tree sheering off the
right side saddle tank and crossover lines. Estimated fuel loss was about 120 GAL on the ground, in a tree and in a
storm drainage ditch along the roadway. Truck was removed from the scene and Shamrock Environmental was called
to the scene to mitigate the fuel spill and conduct the cleanup,
Death: 0 Injuries: 0 Evacuation: 0 Radius: 0
Latitude: 00.000000 Longitude:-00.000000
NOTIFICATIONS
LEMC:
Onscene
ENV MNGT:
Onscene
SO:
Onscene
LFD:
Onscene
SHPISWP:
Onscene
Notes:
1156 - K. Hamby and DPH (PHP&R) emailed and ack. - JB
3/25/2019 2:25:19 PM Page 1 of 1

Beverly, Trudy
From: Beverly, Trudy
Sent: Thursday, February 6, 2020 10:15 AM
To: John Matlock
Subject: RE: [External] UST 61
Good Morning John,
You may want to check the number that you've been calling. It should be [phone]. 1 have not received
any voicemails from you. Thank you for submitting the UST-61 and contact information.
Have a great day,
Trudy
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
_ North Carolina Department of Environmental Quality
EQ�� NR,vN7en[al �� �UST Section, Mooresville Regional Office
704.235.2182 (Office)
Trudy.Beverlykncdenr. gov
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
Office Mailing Address:
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Branch's Underground Storage Tanks Website Address: hops://deq.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: hgps://deg.nc.gov/about/divisions/waste-management/ust/ast-prosram
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httns://deo.nc. eov/about/divisions/waste-management/waste-management-rules-data/waste-management-eis-mans
File Review Procedures:
https://deq.nc. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
hi�2s://deg.nc.gov/about/divisions/waste-management/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
ht_pt s:Hfiles.nc.gov/ncdeq/Waste%2OManagement/DWM/UST/Corrective%2OAction/Electronic%2ODocument%2OSubmittal%2OMemo%2OUpdate.pdf
htips:Hfiles.nc. gov/ncdeq/Waste%2OManagement/D ViM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx
From: John Matlock [mailto:[e-mail]]
Sent: Thursday, February 6, 2020 10:05 AM
To: Beverly, Trudy <[e-mail]>
Cc: John Matlock <[e-mail]>
Subject: [External] UST 61
f• External email. Do not click links or open attachments unless you verify. Send all suspicious email as an
tac"hmewnt to [e-mail]
I have tried to reach you by phone several times unsuccessfully,
Here is the UST-61 and EM-43 with contact info for DLB Trucking and the 6777 Mt. Pleasant Concord release.
Thanks

John Matlock
Shamrock Environmental Corp.
Emergency Response Coordinator
800.881.1098
336.375.8816 Direct Line
336.708.9345 Cell
336.375.1801 Fax
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