MO-88778_95759_CA_UST-62_20200422_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
(DW M USE ONLY)
Suspected Contamination? (YIN)
Facility ID Number
Incident # Risk (H,I,L,U)
Confirmed OW Contamination? (YIN)
Date Leak Discovered
Received On Received By
Confirmed Soil Contamination ?(YIN)
Comm/Non-Commercial?
Reported by (circle one)- Phone, Fax or Report
Samples Taken?(Y/N)
Reg/Non-regulated?
Region
Free Product? (YIN) If Yes, State Greatest
Thickness
INCIDENT DESCRIPTION
Incident Name:
6AJ•CrP5C2rP— 01V
Address: .0
County: C Ft r r U S
City/Town: �
�uic�sanl. 'C
Zip Code:
280��
Regional Office (circle one): Asheville Mooresville 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 resent and recoveryefforts, responses conducted, impacts to rece fors
`initial
ck, - uclK- 4ate- d Cr n4fj V"c,4,:k f)bcv A-wA . hkidLf occurrej
❑Topographic map
❑GISAddress matching
Other
❑Unknown
Describe location:
Iogao s�_1�ury R�
N� �3030
'14 I fib, Lrit,sC(AVCf- 'i-aa-ate 50-100
Of 01 VA-5 I'P t-Asec'. r r ,c i.ry'l A f?I V I 00 a - 11 tlrs w ,i s ,vc1 rej P.A.a , jCjr j,e J v4o
?.e s FhFlv`hFlI F 1
�I [�, fines IN o A lbw f(rrry .�!FP =,. a�7rA: f6r 1),!? I:trrrett 11 11� sr �i��,
Prl .i w;l, rk"I"Jp' �t e.� 4 Fl �f 4/ a D. Iirlli vAYP_f 50, 1 ,,. �. -
� N � n �xc�vn�� .
AtA 54ciea cn, 1�Nad id c6UYre�?. C,1 � 5c1/ Uv,ll %e ;1r�cLC_ of �1� � roved e-
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 ry product type released)
❑ Tank ❑ Spill ❑Petroleum ❑ Gasolinel diesel/ ❑ Diesel/Veg. Oil
❑ Piping ❑ Ovell ❑Non Petroleum Kerosene Blend
❑ Heating Oil ❑ Vegetable Oil 100%
❑ Dispenser ❑Corrosion El Both
❑ Other Petroleum ❑ El — E20
❑ Submersible Turbine Pump ® PhysicaVMechanical
Location Products
❑ Delivery Problem Damage ❑ E21 — E84
(Chock one) El metals
❑ Install Problem
❑ Spill Bucket ❑ E85 — E99
Facili ❑ o
❑Other ❑ #Y Other lnorganics ❑Ethanol 100 /a
❑ Other
❑ Unknown [—]Residence❑ Other Organics
❑ E01 — E09
❑ Unknown
[-]Other
presented on reverse
Definitions presented on reverse
Ownership
1. Municipal 2. Military 3. Unknown 4. Priv toe 5. Federal 6. County 7. State
Operation Two
1. Public Service 2. Agricultural 3- Residential 4- Education/Relig- 5. Industrial 6. Commercial.• 7- Mining
1 ICT C........ - --,
Page 'I 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
! y
Point of Contact
Address
AiA�,f C-00ci,v-,A.4
r
lh4cr : !sc
i e
City
T•i„ •.,.5 e
State Zip Code
Number`
.,� !1
i ll_ ^a: '•-1`
�1T�•ellephopn,e
L u { f k 'i
UST SYSTEM OPERATOR
UST Operator/Company
Address
}Crf:-Ctt
a ?r
City t
State
Zip Code
Telephone Number
LANDOWNER AT LOCATION
OF UST INCIDENT
Landowner
Address
�gq
Y pil t• tlr,C 1. Y tv
fj
City
pp
State
Zip Code
Telephone Number
Draw Sketch of Area (showing two major road intersections) or Attach Map
bdc ll School F,OA�
— loL)dL6G' I C,4�
r=r v d s o,.r Rnr+d
Person Reporting Incident pfA odMAr
Company K,,Ik WA,me Q AN
Telephone Number-)0 3�?11_t! i a
Title Prp e f 4 FAc1bfIrs fly r
Address 35-7 CovCYe5cere PRw qu�c�so,� �ao36
Date v--�Q-QO
u,;� tV,--1 ! Z1)
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 bead (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 pbysical 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 LIST 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

Beverly, Trudy
From:
Beverly, Trudy
Sent:
Monday, April 27, 2020 6:41 AM
To:
Alan Goodman
Cc:
Taraban, Ron
Subject:
RE: [External] Release
Good Morning Alan,
Thank you for the additional information and pictures. No need to fill out the other form. You will receive a Notice of
Regulatory Requirements letter for the release today or tomorrow.
Have a wonderful day,
Trudy
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
North Carolina Department of Environmental Quality
UST Section, Mooresville Regional Office
I�r
704.235.2182 (Office)
Trudy. B everlykncdenn 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:Hdeq.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: https://deg.nc.aov/about/divisions/waste-management/ust/ast-proeram
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httns://dea.ne. 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):
hLtps://deg.nc.gov/about/divisions/waste-manaaement/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
httns:Hfiles.ne.izov/ncdeafWaste%2OMana2ement/DWM/UST/WhatsNew/Final-Electronic-Document-Submittal-Policv.ndf
https:Hfiles.nc.gov/ncdeq/Waste%20Management/D WM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx
From: Alan Goodman[mailto:[e-mail]]
Sent: Sunday, April 26, 2020 9:56 AM
To: Beverly, Trudy <[e-mail]>
Cc: Taraban, Ron <[e-mail]>
Subject: RE: [External] Release
CAUTION:I email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
AAL
Trudy — Late yesterday I received the voicemail you left on Friday. I am not sure if I simply did not see it Friday or if it
appeared yesterday. Regardless, I apologize for the slow response.
Following is the information you requested:
• Type product released
o Waste / used oil

• Storage container
o Above ground tote
• How tote was cracked
o Wayne Brothers, the contractor, was breaking rock
o A piece of rock flew and struck the tote
o This resulted in a 4" crack which allowed the oil to release
If I need to complete a form other than the UST-61, please advise and I will gladly do so.
Pictures, with labels, are attached.
Let me know if there are questions.
Lastly, I am working from home also. Very different from being in the office.
Thanks
MErommu
00NWrRJ0910N ■UPPLV
Alan Goodman
Facilitiy Manager
Administration Group
[phone] [phone]
www.PreferredConstructionSupply.com [preferredconstructionsupply.com]
357 Concrescere Parkway I Davidson I NC 1 28036
From: Beverly, Trudy <[e-mail]>
Sent: Thursday, April 23, 2020 2:45 PM
To: Alan Goodman<[e-mail]>
Cc: Taraban, Ron <[e-mail]>
Subject: RE: [External] Release
Received.
Thank you,
Trudy
Trudy Beverly, L.G.
D- I E Q Hydrogeologist, Division of Waste Management
North Carolina Department of Environmental Quality
LMWrL�nl'0 L � to ft 1W Aj r UST Section, Mooresville Regional Office
704.235.2182 (Office)
Trudy. B everlykncdenn gov
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
701

Office Mailing Address:
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Branch's Underground Storage Tanks Website Address: https://deq.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: https://deq.nc.gov/about/divisions/waste-management/ust/ast-proeram
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httDs:Hdeu.ne. aov/about/divisions/waste-manaeement/waste-manaeement-rules-data/waste-manaaement-eis-mans
File Review Procedures:
https:Hdcq.nc. gov/about/divisions/waste-manaaement/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
httns://deo.nc. aov/about/divisions/waste-manaeement/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
https:Hfiles.nc.gov/ncdeg[Waste%20Manatiement/DWM/UST[WhatsNew/Final-Electronic-Document-Submittal-Policv.pdf
https:Hfiles.nc.gov/ncdeq/Waste%20Management/DWM/UST/Corrective%2OAction/UST%20filc%20names%20for%2OLaserfiche.docx
From: Alan Goodman [mailto:[e-mail]]
Sent: Thursday, April 23, 2020 1:34 PM
To: Beverly, Trudy <[e-mail]>
Cc: Taraban, Ron <[e-mail]>
Subject: [External] Release
External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
[e-mail]
Trudy — I left a voicemail at 704 663-1699 x 400 yesterday at 4:35 PM regarding an oil release. Ron Taraban returned my
call this morning.
He asked me to complete the attached form and email it to you.
The release was cleaned up completely yesterday. The spill kits and soil will be disposed of as soon as we talk with
Charles Gerstel about recommended disposal sites.
Please let me know if additional information is needed.
MEw
dFIrT�JCT1Cf1L ■LJ0ifL1!
Alan Goodman
Facilitiy Manager
Administration Group
k [phone] [phone]
www.PreferredConstructionSupply.com [preferredconstructionsupply.com]
357 Concrescere Parkway I Davidson I NC 128036