The URL can be used to link to this page

Home My WebLink AboutMO-88838_96107_CA_UST-62_20210111_24 Hour Notification of Discharge FormUST-62 24-Hour Notification of Discharge Form For Non -UST This form should be completed and submitted to the UST Section's regional office following a known or suspected release of Releases of petroleum from a source other than an underground storage tank. This form is required to be submitted within 24 hours of Petroleum in NC discovery of a known or suspected petroleum release (DWM USE ONLY) Suspected Contamination? (Y/N) Release Discovered Incident # Priority Rank (H,I,L,U) _ Received (time/date) Confirmed GW Contamination? (Y/ ) Confirmed Soil Contamin Lion ?(Y/N) (time/date): /p 'Of "A Received By Region Samples Taken?(YIN) Free Produ (Y/N) Reported by (circle one): Phone, Fax or Report If Yes(Free product), St a Greatest Thickness: Feet &hfs�L For INCIDENT DESCRIPTION Incident Name: '' 71 Address (street number/name): U D S_ CA m me, j U /r-u , County: T 1 0. DG�v-Nui City/Town: pt I,tN k b �r S Zip Code: �9 og� Regional Office (circle one): Asheville, Mooresville. Fayetteville, Ralei h, Washington, Wilmin ton, Winston Salem ^ Latitude (deawl degrees): 3S' - �O Aq9 Longitude (deamai degrees) : —$� . 60?9 Obtained by: ❑ GPS Describe sage c! or confirmed releas (nature of ease, timg/dat of{ptease, q� ntlty o�relQase, amount of free f} /VN. 'ILI I »5Yv Ei ( H hV 4, �ectronic topographic map ❑ GISAddress matching ❑ Other Linduct a: I T LCC �e&ca! ba.1y,5 {. !'Zi, ," [) 6/w- C , A�I ita t'7L ta'r �o G.,..�` /h c2 fe,+ Ci�l.ir1S ✓ l;/ 5 led -ek a.on 641A/,e[y Describe initial response/abatement (time/date rel ase topp d, rlganup begun/crompl ted quantity of product 74. �,f soil removed, con/kmahon sampling): F+ IQ-i 0 _ w CA( µ,u.s C d-1 /Z/ P, ❑ Unknown Describe location: rae 6+-•�• L'-- bzAe4., I00161 Des 'ibe. impacted receptors: l AAaw4 its 0 tk _ LV-Re � 1�,r S�PLrn , J 1 OW R LEAPE WAS DISCOVERED (Release code) e S bl�.aJkkx-k one) Observation of Release at Occurrence ❑ Water Supply Well Contamination ❑ Visual or Olfactory Evidence ❑ Surface Water Contamination ❑ Soil Contamination ❑ Other (specify) ❑ Groundwater Contamination SOURCE OF CONTAMINATION Source of Release Cause of Release Type of Release Product Tvpe Released (Check one to indicate primary (Check one to indicate primary (Check one (Check one to indicate primary petroleum product source) cause) type released) ❑I AST (tank) ElSpill (Accidental) 2/PetroleumElGasoline/ Diesell ❑ DieseWeg. Oil 144 AST Piping/ Dispenser ❑ Spill (Intentional) ❑ Both Petroleum Kerosene Blend ❑ ❑ AST Delivery Problem ❑ rrosion & Non -Petroleum ❑ Ell - E20 Vegetable Oil 100% ❑ sweating Oil ❑ E21 - E84 ❑ OTR Vehicle Tank Physical or Mechanical Location ❑ E85 - E99 Ur Waste Oil ❑ OTR Bulk Transport Tank Damage (Check one) ❑ Mineral Oil -no ❑ RR Bulk Transport Tank ❑ Equipment Failure ❑ Ethanol 100% PCBs ❑ Facility ❑ Mineral Oil ❑ Transformer ❑ AST Overfill -PCBs ❑ Residence ❑ Other Petroleum ❑ AST Installation Problem ❑ Other ❑ Highway/Road Products ❑ Unknown ❑ Other ❑ Railway ❑ Unknown ❑ Other Definitions resented 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 Guidance presented on reverse — w, rmw vc pre mr 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 List of Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary) 1. 2. 3. PARTY RESPONSIBLE FOR RELEASE (if the source of the release is not an AST system or if it is an AST system and there is a responsible party other than the AST system owned operator) Name of Person/Company . Zs et�A�sd-n/�bw�-ers� Address s3 Lac-eha A--a-� city /0 1J � State G Zip Code late h one ;u7 ber' (G AST SYSTEM OWNER (if the source of the release is an ASTsystem) AST Owner/Company I)IIAI;h 'F:or-d Address I City State Zip Code Telephone Number AST SYSTEM OPERATOR (if the source of the release is anASTsystem) UST Operator/Company Address City State Zip Code Telephone Number LANDOWNER AT LOCATION OF INCIDENT Landowner L_ Address City State Zip Code Telephone Number Draw Sketch of Area or Provide Map (showing incident site, location of release, two major road intersections, potential receptors) Attach sketch or map to form. Give Directions to Incident Site Attach directions to form if necessary. Person Reporting Incident [ yLaf Company (,-- rpm ' Telephone Number qjq 71r Title �l �. Address (] r j�1 7 Date UST Form 62 (04 0)U N.� Page 2 of 2 Definitions of Sources AST (Tank): means the tank is used to store product AST Piping: means the piping and connectors running from the tank to the dispenser or other end -use equipment AST Dispenser: includes the dispenser and the equipment used to connect the dispenser to the piping AST Delivery Problem: identifies releases that occurred during product delivery to the tank. OTR Vehicle Tank: means the tank is used to store product to fuel an over the road vehicle OTR Bulk Transport Tank: means a tank that is used to transport product in bulk over the road (by truck) RR :bulk Transport Tank: means a tank that is used to transport product in bulk by train Transformer: means electrical transformer Other serves as the option to use when the release source is known but does not fit into one of the preceding categories Unknown: identifies releases for which the source has not been determined Definitions of Causes Spill (Accidental): use this cause when a spill occurs accidentally(e.g., when the delivery hose is disconnected from a fill pipe) Spill (Intentional): use this cause when a spill occurs intentionally (e.g., intentional dumping or breakage) Corrosion: use when a metal tank, piping, or other component has a release due to corrosion Physical or Mechanical Damage: use for all types of physical or mechanical damage, except corrosion Equipment failure: use when a release occurs due to equipment failure other than corrosion or physical or mechanical damage AST Overfill: use when an overfill occurs (e.g., overfills may occur from the fill pipe at the tank or when the nonle fails to shut off at the dispenser) AST Installation Problem: use when the problem is determined to have occurred specifically because the AST system was not installed properly Other. use this option when the cause is known but does not fit into one of the preceding categories Unknown: use when the cause has not been determined Guidance: Ownership and Operator Type Ownership select the category which describes owner of the AST system, bulk transport tank, or other release source Operator Type select the category which describes the operation in which owner uses the AST system, bulk transport tank, or other release source Beverly, Trudy From: Beverly, Trudy Sent: Tuesday, January 12, 2021 8:57 AM To: steve@lighthousetechcorp.com Subject: RE: [External] Waste oil spill at Hilbish Ford, Kannapolis Steve, Thank you for emailing the release reporting form. Trudy Trudy Beverly, L.G. Hydrogeologist, Division of Waste Management ie D-- I E Q North Carolina Department of Environmental Quality 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. Office Mailing Address: 610 East Center Avenue, Suite 301 Mooresville, NC 28115 Branch's Underground Storage Tanks Website Address: hops://deq.nc.gov/about/divisions/waste-manaaement/ust Branch's Above Ground Storage Tanks Website Address: ht!ps:Hdeg.nc.gov/about/divisions/waste-management/ust/ast-proeram INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES: httns://deo.nc. 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): hops: //deg.nc. gov/about/divisions/waste-management/laserfiche Document Submittal & UST File Names for Laserfiche Policies: httys:Hfiles.nc.eov/nedeci/Waste%2OMana2ement/DWM/UST/WhatsNew/Final-Electronic-Document-Submittal-Policy.odf htips:Hfiles.nc. gov/ncdeq/\Vaste%2OManagement/D WM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx From: steve@lighthousetechcorp.com [mailto:steve@lighthousetechcorp.com] Sent: Monday, January 11, 2021 5:02 PM To: Beverly, Trudy <trudy.beverly@ncdenr.gov> Subject: RE: [External] Waste oil spill at Hilbish Ford, Kannapolis CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to Report Spam. Ust-62 attached. Thanks Steve Steven B. Lucas, L.G. Environmental Geologist Lighthouse Technical, P.C. PO Box 1379 Huntersville, North Carolina 28070 704-237-4209 Office 704-439-7439 Cell www.lighthousetechcorp.com From: Beverly, Trudy <trudy.beverly@ncdenr.gov> Sent: Monday, January 11, 2021 11:42 AM To: Steve Lucas <sblucas@charlotte.twcbc.com> Subject: RE: [External] Waste oil spill at Hilbish Ford, Kannapolis Please email a UST-62 form when completed. Thanks, rumm �/ Trudy Beverly, L.G. Hydrogeologist, Division of Waste Management North Carolina Department of Environmental Quality UST Section, Mooresville Regional Office 704.235.2182 (Office) Trudy.B everly(ancdenr. 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: hops://deg.nc.gov/about/divisions/waste-management/ust Branch's Above Ground Storage Tanks Website Address: hgps:Hdeg.nc.gov/about/divisions/waste-management/ust/ast-prosram INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES: httDs://deo.nc. eov/about/divisions/waste-manaeement/waste-manaeement-rules-data/waste-manaeement-eis-mans File Review Procedures: hops://deq.nc. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche): hitps://deq.nc.gov/about/divisions/waste-management/laserfiche Document Submittal & UST File Names for Laserfiche Policies: htti)s:Hfiles.nc.¢ov/ncdeci/Waste%2OManaizement/DWM/UST[WhatsNew/Final-Electronic-Document-Submittal-Policv.adf https:Hfiles.nc. gov/ncdeq/Waste%2OManagement/DWM[UST/Corrective%2OAction/UST%2Ofile%20names%20for%2OLaserfiche.docx -----Original Message ----- From: Steve Lucas [mailto:sblucas@charlotte.twcbc.com] Sent: Monday, January 11, 2021 11:29 AM To: Beverly, Trudy <trudy.beverly@ncdenr.gov> Subject: [External] Waste oil spill at Hilbish Ford, Kannapolis CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to Report Spam.<mailto:report.spam@nc.gov> Hi Trudy Did you get a report on a spill at Hilbish last Friday ? If not can you call me at 704-439-7439 Thanks Steve Lucas Sent from my iPhone