MO-9552_40984_CA_CLO_20200128_Home Heating Oil UST Closure

Geological Resources, Inc.
January 29, 2020
Ms. Trudy Beverly
NCDEQ-UST Section
Mooresville Regional Office
610 East Center Ave.
Mooresville, NC 28115
Re: Soil Sampling Report
5012 Churchill Drive
Charlotte, Mecklenburg County
North Carolina, 28269
GRI Project No: 5295
Dear Ms. Beverly,
Please find enclosed the referenced report for the above mentioned site.
If you have any questions, please contact Randy Smith at 704-845-4010.
Sincerely,
Geological Resources, Inc.
�'x' d' )"L,
Leslie Maxtone-Graham
Administrative Assistant
Enclosure
Cc: Ms. Michele Alexander, file
3502 Hayes Road • Monroe, North Carolina 28110
113 West Firetower Road, Suite G • Winterville, North Carolina 28590
Phone [phone] • [phone] • Fax [phone]

Geological Resources, Inc.
January 28, 2020
Ms. Michele Alexander
8632 Sequoia Grove Lane
Charlotte, North Carolina 28214
Re: Soil Sampling Report
5012 Churchill Drive
Charlotte, Mecklenburg County
North Carolina, 28269
GRI Project No. 5295
Dear Ms. Alexander,
Geological Resources, Inc. (GRI) presents this information to complete the scope of work that was
requested in proposal number 20-016 for the above referenced site. Please find enclosed the applicable
laboratory report, summary of soil sample analytical results, boring logs and photo sheets.
On January 17, 2020, GRI personnel advanced two soil borings (SB-1 and SB-2) in the vicinity of the
residential 500-gallon home heating oil underground storage tank (UST). One soil sample was collected
from each boring, SS-1-7' from SB-1 on the northeast side, and SS-2-7' from SB-2 on the southwest side,
directly adjacent to the UST, at a depth of seven (7) feet.
The soil samples (SS-1-7' & SS-2-7') were submitted for laboratory analysis of total petroleum
hydrocarbons (TPH) gasoline -range organics (GRO) by EPA Method SW846/8015C and diesel -range
organics (DRO) by EPA Method SW846/8015C. Concentrations of requested method constituents which
exceeded the Regulatory Action Levels were reported in both SS-1-7' & SS-2-7'. A summary of soil
analytical data is presented in Table 1. A complete laboratory report has been included as Appendix A.
Soil boring logs are provided in Appendix B.
Due to the tank being in close proximity to the structure's foundation, the heating oil tank was closed in -
place rather than closed by removal. On January 23, 2020 GRI personnel supervised the in -place closure
of the heating oil UST. The tank was determined to be empty. The fill port was cut off below grade. GRI
subcontractor "Tailored Foam" arrived on site and filled the 500-gallon tank with inert foam. The fill port
was then capped with concrete below grade and covered with soil. Photo documentation of tank closure
is provided as Appendix C.
A Notice of Residual Petroleum (NRP) was mailed to you on January 23, 2020 to be completed, notarized
and mailed to the NCDEQ Mooresville Regional office. Upon our receipt from the NCDEQ Regional
office, the NRP will be recorded at the Mecklenburg County Register of Deeds.
Based on analytical results from the collected soil samples, a petroleum release was confirmed on the
property. A UST-61, Notification of Release Form was submitted to NCDEQ on January 28, 2020. The
site is currently serviced by a municipal water supply and a site reconnaissance of the area did not identify
3502 Hayes Road • Monroe, North Carolina 28110
113 West Firetower Road, Suite G • Winterville, North Carolina 28590
Phone [phone] • [phone] • Fax [phone]

5012 Churchill Drive
Charlotte, Mecklenburg County
Soil Sampling Report
Page 2 of 2
a water supply well within 150 feet of the heating oil tank. A copy of the UST-61 form is provided as
Appendix D.
Please do not hesitate to contact the undersigned at [phone] if you have any
additional information.
Sincerely,
Geological Resources,
Inc.
`
Corey N. Buchanan, P.G.
Project Manager
Enclosures:
Table 1: Summary of Soil Analytical Results
Appendix A:
Soil Sample Laboratory Report
Appendix B:
Soil boring logs
Appendix C:
Photo sheets
Appendix D:
UST-61 Form
cc: file
Randy A. Smith, P.G.
Project Manager
l,.�
�tiCE PJS p?.
SEAL
1262
3502 Hayes Road • Monroe, North Carolina 28110
113 West Firetower Road, Suite G • Winterville, North Carolina 28590
Phone [phone] • [phone] • Fax [phone]

Figures

'
drB
-i- qrl r a ' • i ?tiff
- - � - •. � � . y - it :- •
5 % "f
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-
IJ �
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•k J
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7�
:{ y
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I ii
1 , Figure 1
�. Site Location
5012 Churchill Drive
' *FfFfF�` 5012 Churchill Drive Charlotte
lk■ ! ..
Mecklenburg County, NC
G 500 M Incident No. N/A
C A� 2000 FT GRI Project No. 5295
Date:01/23/2020 Location:35.287856°N 80.811111°W

LEGEND
SUBJECT PROPERTY BOUNDARY LIN
TREE LINE
- — — — — — — - UNDERGROUND STORAGE TANK
f SOIL SAMPLE LOCATION
QF FILL PORT
Note:
1. This Site Map is based on data from the Mecklenburg
County, NC GIS office.
2. This site was not professionally surveyed; site features and
utilities are approximate.
CHRUCHILL DR.
1 1
1 1
270—Gallon
UST
1 SB-2-7' SB-1-7' 1
1 1
I �GRASS� I
1 5012 1
1 1
I I
1 1
I 1
�CONCRETE� I
1 1
1 1
I I
1 1
1 �TREES�',, 1
41
SITE MAP
0 15 30 60
5012 Churchill Drive 5012 Churchill Drive
Incident No. N/A Charlotte Mecklenburg County,
( IN FEET) GRI Project No. 5295 NC
G'eo%gicc/ Resources, Inc. 1 inch =30 ft Date: 01/13/2020 1 Drawn by: DTH I Figure: 2

Table 1:
Summary of Soil Analytical Results

TABLE 1
SUMMARY OF SOIL ANALYTICAL RESULTS
5012 CHURCHILL DRIVE
Date: 01 /27/2020
Analytical Method
SW846 8015C
SW846 8015C
Contaminant of Concern 4
C?
�
Date Collected
Sample Depth
Sample ID
(mm/dd/yy)
(feet)
RAL (mg/kg)
50
100
SS-1-7'
01 /17/20
7
39.6
446
SS-2-7'
01 /17/20
7
22.4
13,800
Notes:
• Results reported in mg/kg (milligrams per kilograms)
• RAL: Regulatory Action Levels
• Concentrations in bold face type exceeded the RALs and/or soil to water MSCCs.
• NE: Not Established
Page 1 of 1

Appendices

Appendix A:
Soil Sample Laboratory Report

ffm
Orlando, FL
The results set forth herein are provided by SGS North America Inc. a-Hl ydcopy 2. 0
Automated Report
Technical Report for
GRI (Geological Resources Inc.)
5012 Churchill Dr, Charlotte, NC
5295
SGS Job Number: FA71738
Sampling Date: 0l/ 17/20
Report to:
j ohnbrown@geologicalresourcesinc. com
jra@geologicalresourcesinc. com
ATTN: Distribution5
Total number of pages in report: 12
Ac Fp
Test results contained within this data package meet the requirements Caitlin Brice, M. S.
of the National Environmental Laboratory Accreditation Program General Manager
and/or state specific certification programs as applicable.
Client Service contact: Muna Mohammed 407-425-6700
Certifications: FL(E83510), LA(03051), KS(E-10327), IL(200063), NC(573), NJ(FL002), NY(12022), SC(96038001)
DoD ELAP(ANAB L2229), AZ(AZ0806), CA(2937), TX(T104704404), PA(68-03573), VA(460177),
AK, AR, IA, KY, MA, MS, ND, NH, NV, OK, OR, UT, WA, WV
This report shall not be reproduced, except in its entirety, without the written approval of SGS.
Test results relate only to samples analyzed.
SGS North America Inc. • 4405 Vineland Road • Suite C-15 • Orlando, FL 32811 • tel: [phone] • fax: [phone]
SGS is the sole authority for authorizing edits or modifications to this document. Please share your ideas about
Unauthorized modification of this report is strictly prohibited. how we can serve you better at:
Review standard terms at: http://www.sgs.com/en/terms-and-conditions [e-mail]
1 of 12
FA71738

Sections:
Table of Contents
-1-
Section1: Sample Summary................................................................................................... 3
Section2: Summary of Hits.................................................................................................... 4 w
Section3: Sample Results-------------------------------------------------------------------------------------------------------- 5
3.1: FA71738-1: SB-1-7....................................................................................................... 6
3.2: FA71738-2: SB-2-7....................................................................................................... 8
Section4: Misc. Forms............................................................................................................ 10
4.1: Chain of Custody........................................................................................................... 11
6 2of12
FA71738

SGS LabLink@19:28 27-Jan-2020
Sample Summary
GRI (Geological Resources Inc.)
5012 Churchill Dr, Charlotte, NC
Project No: 5295
Job No: FA71738
Sample Collected Matrix Client
Number Date Time By Received Code Type Sample I D
FA71738-1 01/17/20 10:11 CB 01/18/20 SO Soil S13-1-7'
FA71738-2 01/17/20 10:20 CB 01/18/20 SO Soil SB-2-7'
Soil samples reported on a dry weight basis unless otherwise indicated on result page.
6 3of12
FA71738

Summary of Hits
Job Number:
FA71738
Account:
GRI (Geological Resources Inc.)
Project:
5012 Churchill Dr, Charlotte, NC
Collected:
01/ 17/20
Lab Sample I D Client Sample I D Result/
Analyte Qual RL MDL Units Method
FA71738-1 SB-1-7'
TPH-GRO (C6-C10)
39.6 13
TPH (C 10-C28) a
446 41
FA71738-2 SB-2-7'
TPH-GRO (C6-C 10)
22.4 7.3
TPH (C10-C28)
13800 3200
(a) Petroleum hydrocarbon pattern extends beyond C28.
6.4 mg/kg SW846 8015C
20 mg/kg SW846 8015C
3.7 mg/kg SW846 8015C
1600 mg/kg SW846 8015C
Page lofl
6 4of12
FA71738

i
SG$f
Orlando, FL im
Section 3
Sample Results
Report of Analysis
6 5of12
FA71738

SGS LabLink@19:28 27-Jan-2020
Report of Analysis
Client Sample I D: SB-1-7'
Lab Sample I D: FA71738-1 Date Sampled: 01/17/20
Matrix: SO - Soil Date Received: 01/18/20
Method: SW846 8015C Percent Solids: 60.2
Project: 5012 Churchill Dr, Charlotte, NC
Page 1 of 1 j
File I D DF Analyzed By Prep Date Prep Batch Analytical Batch
Run #1 1U283.13 1 01/21/20 13:37 SH n/a n/a G1U11
Run #2
Initial Weight Final Volume Methanol Aliquot
Run #1 4.33 g 5.0 ml 100 ul
Run #2
CAS No.
Compound
TPH-GRO (C6-C 10)
CAS No.
Surrogate Recoveries
460-00-4
4-Bromofluorobenzene
98-08-8
aaa-Trifluorotoluene
Result
RL M DL Units Q
39.6
13 6.4 mg/kg
Run#1
Run#2 Limits
143%
56-149%
98%
66-132%
ND
= Not detected MDL = Method Detection Limit
J =
Indicates an estimated value
RL
= Reporting Limit
B =
Indicates analyte found in associated method blank
E =
Indicates value exceeds calibration range
N =
Indicates presumptive evidence of a compound
6 6of12
FA71738

SGS LabLink@19:28 27-Jan-2020
Report of Analysis
Client Sample I D: SB-1-T
Lab Sample I D: FA71738-1 Date Sampled: 01/17/20
Matrix: SO - Soil Date Received: 01/18/20
Method: SW846 8015C SW846 3546 Percent Solids: 60.2
Proj ect: 5012 Churchill Dr, Charlotte, NC
Page 1 of 1 j
File I D DF Analyzed By Prep Date Prep Batch Analytical Batch
Run #1 WW23159.1) 5 01/22/20 20:37 SJL O1/21/20 10:21 OP78602 GWW947
Run #2
Initial Weight Final Volume
Run #1 20.4 g 1.0 m1
Run #2
CAS No. Compound Result
TPH (C10-C28) a 446
CAS No. Surrogate Recoveries Run# 1
84-15-1 o-Terphenyl 88%
(a) Petroleum hydrocarbon pattern extends beyond C28.
RL MDL Units Q
41 20 mg/kg
Run#2 Limits
56-122%
ND
= Not detected MDL = Method Detection Limit
J =
Indicates an estimated value
RL
= Reporting Limit
B =
Indicates analyte found in associated method blank
E =
Indicates value exceeds calibration range
N =
Indicates presumptive evidence of a compound
6 7of12
FA71738

SGS LabLink@19:28 27-Jan-2020
Report of Analysis
Client Sample I D: S13-2-7'
Lab Sample I D: FA71738-2 Date Sampled: 01/17/20
Matrix: SO - Soil Date Received: 01/18/20
Method: SW846 8015C Percent Solids: 76.7
Prcj ect: 5012 Churchill Dr, Charlotte, NC
Page 1 of 1 N
File I D DF Analyzed By Prep Date Prep Batch Analytical Batch
Run #1 1U284.13 1 01/21/20 14:10 SH n/a n/a G1U11
Run #2
Initial Weight Final Volume Methanol Aliquot
Run #1 5.61 g 5.0 ml 100 ul
Run #2
CAS No.
Compound
TPH-GRO (C6-C 10)
CAS No.
Surrogate Recoveries
460-00-4
4-Bromofluorobenzene
98-08-8
aaa-Trifluorotoluene
Result
RL M DL Units Q
22.4
7.3 3.7 mg/kg
Run#1
Run#2 Limits
147%
56-149%
99%
66-132%
ND
= Not detected MDL = Method Detection Limit
J =
Indicates an estimated value
RL
= Reporting Limit
B =
Indicates analyte found in associated method blank
E =
Indicates value exceeds calibration range
N =
Indicates presumptive evidence of a compound
6 8of12
FA71738

SGS LabLink@19:28 27-Jan-2020
Report of Analysis
Page 1 of 1 N
Client Sample I D:
S13-2-7'
Lab Sample I D:
FA71738-2 Date Sampled: 01/17/20
Matrix:
SO - Soil Date Received: 01/18/20
Method:
SW846 8015C SW846 3546 Percent Solids: 76.7
Prcj ect:
5012 Churchill Dr, Charlotte, NC
File I D DF Analyzed By Prep Date Prep Batch Analytical Batch
Run #1 WW23188.1) 500 01/23/20 14:51 SJL O1/21/20 10:21 OP78602 GWW948
Run #2
Initial Weight Final Volume
Run #1 20.2 g 1.0 M1
Run #2
CAS No. Compound
Result
RL M DL Units Q
TPH (C10-C28)
13800
3200 1600 mg/kg
CAS No. Surrogate Recoveries
Run# 1
Run# 2 Limits
84-15-1 o-Terphenyl
0% a
56-122%
(a) Outside control limits due to dilution.
ND
= Not detected MDL = Method Detection Limit
J =
Indicates an estimated value
RL
= Reporting Limit
B =
Indicates analyte found in associated method blank
E =
Indicates value exceeds calibration range
N =
Indicates presumptive evidence of a compound
6 9of12
FA71738

i
SGS
f
Orlando, FL AM
Section 4
Misc. Forms
Custody Documents and Other Forms
Includes the following where applicable:
• Chain of Custody
6 10 of 12
FA71738

SGS North America Inc - Orlando FR-vTn
Ci-6 Chain of Custody SGS- ORLANDOJOB#: . PAGE—L—AF
� 4405vine C-tUa, Fsenir
TaL407-425ZOGFAX: 407-425-0707
Client / Reporting Information _ Pro'ect Information
�-Project
SGS - ORLANDO Quote # -
, ' =�`. „ '. Analytical Information
SKIFF #
`< Matrix Codes
nn mg
Company Name: I
d r., r I
Name: i�
{'
IS
(,
i
ti
Y
Water
GW - Ground
Water
W W -Water
SW - Surface
Water
SO - Soil
SL- Sludge
01-011
LIQ - Other Liquid
AIR - Air
SOL-Othe S olid
LAB USE ONLY
Address: ,( RWUQ'�
15-27, 4J
Street �a .. r ,� .v
city: State: /V "P:
/Email:
' y Ai
Project CoMaet„0� n n
LL V , '°- yr
Protect#
r
Phone #:
- 9 �- i
Fa r%—
Sampler(s) Names) (Printed)
Sam ler1: a ler2:
Client Purchase Order #
SGS
Orlando
Sample #
Field ID / Point of Collection
LOLLECDON
sAMk..
Naraix
c(arr.
TorAiM
of
corn
ERNFORMMx1
I i
s�
8
"� pk'
- $
ze
L
lk,#
+
rneround Time Business days)
,`. ri t�!
Data Deliverable Information
"'4'"--`�" Comments / Remarks
Tr' Sht, i - ( '
D Day usiness) Approved By: I Date:
y
5 Day
3 Day RUSH
2 Day RUSH
1 Day RUSH
Other
Rush TIA Data Available VIA Email or ablink
v, , _-,gam' ,11 , ,,.^,: SampleCustody must be
❑COMMERCIAL "A" (RESULTS ONLY)
nq COMMERCIAL "B" (RESULTS PLUS QC)
REDTI (EPALEVEL3)
�ULI.Tl (EPA LEVEL 4)
DO'S
documented below each time samPies chargepossession, includin
+
4- YlS )' 10122C
,
courier delive-
Relinqulahatl 6 Sa pI d ffiliation
1 ( ..
Date Time:
)/ )�"! &r4J )1�
Recelved By/Affiliation
2 '�(ci e I� 3 �- ��
Relinquished By/Affillaton
3
Date Time
R.-ived B IAHIIi;ion
4 00
Relinquish by/Affiliation
5
Date Time:
Received BylAffilation
S
Relinquished SylAffillation
T
Date Time:
I Recelved By/Affiliation
8
Lab Use Onl : cooler Temperature s Celsius (corrected): htl :/ .c mlen/ter and-conditlons
ORLD-SMT-0001-03-FORM-COC (1) Rev 031318 u'
FA71738: Chain of Custody
Page 1 of 2
deiii 11 of 12
FA71738

SGS Sample Receipt Summary
Job Number: FA71738 Client: GEOLOGICAL RESOURCES Project: 5012 CHURCHICE
Date / Time Received: 1/18/2020 8:00:00 AM DeliveryMethod: FX Airbill We:
Therm ID: IR 1; Therm CIF: -0.8;
# of Coolers: 1
Cooler Temps (Raw Measured) °C: Cooler 1: (3.3);
Cooler Temps (Corrected) °C: Cooler 1: (2.5);
Cooler Information Y or N
Sample Information
Y
or N
N/A
1. Custody Seals Present W ❑
1. Sample labels present on bottles
0
❑
2. Custody Seals Intact W ❑
2. Samples preserved properly
❑�
❑
3. Temp criteria achieved ❑d ❑
3. Sufficient volume/containers recvd for analysis:
❑�
❑
4. Cooler temp verification IR Gun
4. Condition of sample
Intact
5. Cooler media Ice(Bag
5. Sample recvd within HT
0
❑
6. Dates/Times/IDs on CDC match Sample Label
0
❑
Trio Blank Information Y or N N/A
7. VOCs have headspace
❑
❑
0
1. Trip Blank present / cooler ❑ ❑ ❑i
8. Bottles received for unspecified tests
❑
0
2. Trip Blank listed on COC ❑ ❑ 0
9. Compositing instructions clear
❑
❑
k
W or S N/A
10. Voa Soil Kits/Jars received past 48hrs?
❑
❑
❑d
11. % Solids Jar received?
❑
❑
0
3. Type Of TB Received ❑ ❑ W
12. Residual Chlorine Present?
❑
❑
❑,�
Misc. Information
Number of Encores: 25-Gram 5-Gram Number
of 5035 Field Kits: Number of Lab Filtered Metals:
Test Strip Lot #s: pH 0-3 230315
pH 10-12 219813A Other: (Specify)
Residual Chlorine Test Strip Lot #:
Comments
smool Technician: PETERH Date: 1/18/2020 8:00:00 AM Reviewer: Date:
Rev. Date 05/24/17
FA71738: Chain of Custody
Page 2 of 2
6 12 of 12
FA71738

Appendix B:
Soil Boring Logs

Geological Resources, Inc.
3502 Hayes Road
Monroe, NC 28110
SUBSURFACE LOG
Phon [phone]
Fax: [phone]
Project 5012 Churchill Drive
Address 5012 churchill Drive, Charlotte, Mecklenburg County, North Carolina
Boring Number sB-1 Date Drilled 01/17/20
Sample Method Grab
Completion Details Borir
Driller Core
Drilling Method 3.25" OD Hand Auf
installed to total depth and abandoned with soil cuttings
N. Buchanan, NCWL # 4417-B Log By Corey N. Buchanan, GRI
Lab Sample I OVA
Depth Sample interval(ft)l ppm LITHOLOGY
0' - 7' Red clay, odors at 6' - 7'
0
6
SS-1-7' 7' 99.2 TD=7'
12
18
24
30
36
42

Geological Resources, Inc.
3502 Hayes Road
Monroe, NC 28110
SUBSURFACE LOG
Phon [phone]
Fax: [phone]
Project 5012 Churchill Drive
Address 5012 churchill Drive, Charlotte, Mecklenburg County, North Carolina
Boring Number sB-2 Date Drilled 01/17/20
Sample Method Grab
Completion Details Borir
Driller Core
Drilling Method 3.25" OD Hand Auf
installed to total depth and abandoned with soil cuttings
N. Buchanan, NCWL # 4417-B Log By Corey N. Buchanan, GRI
Lab Sample I OVA
Depth Sample interval(ft)l ppm LITHOLOGY
0' - 7' Red clay, odors at 6' - 7'
0
6
SS-2-7' 7' 99.8 TD=7'
12
18
24
30
36
42

Appendix C:
Photo Sheets

A7
as
WADI?,
Au
Photo 3: "Tailored Foam" set up at the residence to fill the tank with inert foam
Photo 4: Inert foam being pumped into the tank

41 4L-
Z4P
N
A4--'
A�
b

am
Photo 7: Concrete cap backfilled with soil
Photo 8: Area of UST after in -place closure with inert foam

Appendix D
UST-61 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)
Suspected Contamination? (Y/N)
Facility ID Number _NA
Incident # Risk (H,I,L,U)
Confirmed GW Contamination? (Y/N)
Date Leak Discovered _1-24-2020_
Received On Received By
Confirmed Soil Contamination ?(Y/N)
Comm/Non-Commercial? non -Comm
Reported by (circle one): Phone, Fax or Report
Samples Taken?(Y/N)
Reg/Non-regulated? _Non-reg
Region
Free Product? (Y/N) If Yes, State Greatest
Thickness
INCIDENT DESCRIPTION
Incident Name: 5012 Churchill Drive Residence
Address: 5012 Churchill Drive
County:
Regional Office (circle one): Asheville, Mooresville, Fayetteville,
City/Town:
Zip Code:
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, impacts to receptors)
❑Topographic map
❑GIS Address matching
❑Other
❑ Unknown
Describe location:
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)
SOURCE OF CONTAMINATION
Source of Release
Cause of Release Type of Release Product Type Released
(Check primary source)
(Check primary cause) (Check one) (Check primary product type released)
❑ Tank
❑ Spill ❑ Petroleum ❑ Gasoline/ Diesel/ ❑ Diesel/Veg. Oil
❑ Piping
❑ Overfill ❑ Non -Petroleum Kerosene Blend
❑ Dispenser
❑Heating Oil ❑ Vegetable Oil 100%
❑Corrosion Both
❑
Other Petroleum E10 - E20
❑ ❑
❑ Submersible Turbine Pump
Physical/Mechanical
❑ Delivery Problem
Products
Damage Location ❑ E21 - E84
(Check one) Metals
❑
❑ Install Problem ❑ E85 - E99
❑ Spill Bucket
Other [-]Facility ❑ Other Inorganics
❑ [:]Ethanol 100%
❑ Other
❑ Other Organics
❑ Unknown ❑Residence ❑ E01 - E09
❑ Unknown
❑Other
Definitions presented on reverse
Definitions resented on reverse
Ownership
1. Municipal 2. Military 3. Unknown
4. Private 5. Federal 6. County 7. State
Operation Type
1. Public Service 2. Agricultural 3.
Residential 4. Education/Relig. 5. Industrial 6. Commercial 7. Mining
UST Form 61 (02/19) 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:
1.
2.
3.
(Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
UST Owner/Company
UST SYSTEM OWNER
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
State
Zip Code
Telephone Number
Draw Sketch of Area (showing two major road intersections) or Attach Map
Person Reporting Incident
Company
Telephone Number
Title
Address
Date
UST Form 61 (02/19)
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 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