MO-9583_47014_CA_UST-61_20200327_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) Y
Facility ID Number
Incident # Risk (H,I,L,U)
Confirmed GW Contamination? (Y/N) N
Date Leak Discovered 3/13/2020
Received On Received By
Confirmed Soil Contamination ?(Y/N) N
Comm/Non-Commercial? Non-com
Reported by (circle one): Phone, Fax or Report
Samples Taken?(Y/N) _ N
Reg/Non-regulated? Non -Reg
Region
Free Product? (Y/N) If Yes, State Greatest
Thickness
INCIDENT DESCRIPTION
Incident Name: Curry Vail LLC
Address: 2553 Vail Avenue
County: Meckl
Regional Office (circle one): Ashevill , Mooresville, ayetteville,
city/Town: Charlotte
Zip Code: 28207
Raleigh, Washington, Wilmington, WI
Latitude (decimal degrees): 35.203461 Longitude (decimal degrees) : _80.813989
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 rece tors
❑Topographic map
F]GIS Address matching
❑Unknown
Describe location:
Two (2) hand auger borings adjacent to both tank ends observed soil staining and
petroluem odors. No sampling conducted. pq
IV❑Other
HOW RELEASE WAS DI c d)
T
(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
® Heating Oil ❑ Vegetable Oil 100%
❑ Dispenser ®Corrosion ❑Both
❑ Other Petroleum ❑ E10 — E20
❑ Submersible Turbine Pump ❑ Physicai/Mechanical Location Products
❑ E21 — E84
Damage
❑ Delivery Problem ❑
❑ Install Problem (Check one) Metals ❑ E85 — E99
❑ Spill Bucket ❑ Other Inorganics
❑ Other [:]Facility Other
100%
❑ Other Residence ❑ Other Organics ❑ E01 — E09
El Unknown
❑ Unknown
[:]Other
Definitions presented on reverse
Definitions presented on reverse
Ownership
1. Municipal 2. Military 3. Unknow 4. Private Federal 6. County 7. State
Operation Type
1. Public Service 2. Agricultural Residential 4. Education/Relig. 5. Industrial 6. Commercial 7. Mining
UST Form 61 (02/19) rays 1 v1

IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected? 1. Yes 2. No Unknow
Number of Water Supply Wells Affected
Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional shoat if necessary)
1.
2.
3.
UST SYSTEM OWNER
UST Owner/Company
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
C a�1Z
/P.D1 63 k.,P- K&-9
City
State
Zip Code
Telephone Number
C L t *r'-'aV f-r£
/V
2 e1­0-3
7,o`F' 6 e t v l z z
Draw Sketch of Area (showing two major road intersections) or Attach Map
See Attached investigation report
Person Reporting Incident
Company
Telephone Number
Title
Address
Date
UST Form 61 (02/19)
Page 2 or A
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