MO-9552_40984_CA_UST-61_20200128_24-Hour Release and UST Leak 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)
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

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

Beverly, Trudy
From:
Beverly, Trudy
Sent:
Tuesday, January 28, 2020 11:08 AM
To:
Joanna Alley
Cc:
Corey Buchanan
Subject:
RE: [External] 5012 Churchill Drive
Received.
Trudy
Trudy Beverly, L.G.
D-�IE Hydrogeologist, Division of Waste Management
North Carolina Department of Environmental Quality
IFepnrlren[ol Gma'nn mental4w
UST Section, Mooresville Regional Office
704.235.2182 (Office)
Trudy. B everlyAncdenn 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: https://deg.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: hit2s://deq.nc.gov/about/divisions/waste-management/ust/ast-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httns://dea.nc. gov/about/divisions/waste-management/waste-management-rules-data/waste-management-gis-mans
File Review Procedures:
hops://deq.ne. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
fts://deq.nc.gov/about/divisions/waste-manaizement/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
https:Hfiles.nc.gov/ncdeq/Waste%2OManagement/D WMIUST/Corrective%2OAction/Electronic%2ODocument%2OSubmittal%2OMemo%2OUpdate.pdf
https:Hfiles.nc. gov/ncdeq/Waste%2OManagement/D WM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx
From: Joanna Alley[mailto:[e-mail]]
Sent: Tuesday, January 28, 2020 10:04 AM
To: Beverly, Trudy <[e-mail]>
Cc: Corey Buchanan<[e-mail]>
Subject: [External] 5012 Churchill Drive
M External email. Do not click links or open attachments unless you verify. Send all suspicious email as an
attachment to report.spam@nc.i?ov
Good Morning Trudy,
On behalf of Corey Buchanan, please see the attached UST-61 form.
Best Regards,
Joanna Alley, E.I.T.
Project Manager

Geological Resources, Inc.
3502 Hayes Road
Monroe, NC 28110
Main [phone] Fax [phone]
[e-mail]
www.geologicalresourcesinc.com
NCPCM Vendor of the Year Recipient