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HomeMy WebLinkAboutMO-9583_47014_CA_UST-61_20200327_24-Hour Release and UST Leak Reporting FormUST-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