MO-28859_48069_CA_UST-61_20211026_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 N/A
Incident # Risk (H,I,L,U)
Confirmed GW Contamination? (Y/N) N
Date Leak Discovered 10/7/21
Received On Received By
Confirmed Soil Contamination ?(Y/N)
Comm/Non-Commercial? NC
Reported by (circle one): Phone, Fax or Report
Samples Taken?(Y/N) y
Reg/Non-regulated? NR
Region
Free Product? (Y/N) If Yes, State Greatest
Thickness
INCIDENT DESCRIPTION
Incident Name: 1025 Concord Parkway, LLC
Address: 1025 Concord Parkway North
County: Cabarrus
Regional Office (circle one): Ashevill Mooresville ayetteville,
City/Town: Concord
Zip Code: 28027
Raleigh, Washington, Wilmington, Wins o -
Latitude (decimal degrees): 35.428685 Longitude (decimal degrees) : 80.612186
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
❑x Other
❑ Unknown
Describe location:
A release of heating oil was identified during UST assessment activities. Free product was not observed.
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
Heating Oil ❑ Vegetable Oil 100%
❑❑ Dispenser Corrosion Both
❑❑
❑ Other Petroleum ❑ El — E20
❑ Submersible Turbine Pump ❑ Physical/Mechanical
Location Products
❑ Delivery Problem Damage (Check one) Metals ❑ E21 — E84
❑
❑ Install Problem ❑ E85 — E99
❑ Spill Bucket ❑ Other Inorganics
❑ Other []Facility Other
100%
❑ Other ❑ Other Organics
❑ Unknown ❑Residence ❑ E01 — E09
❑ Unknown
[—]Other
Definitions presented on reverse
Definitions presented 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 esidenti 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 3cjn now
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
Point of Contact
Address
City
State
Zip Code
Telephone Number
UST SYSTEM OPERATOR
UST Operator/Company
Address
Same
City
State
Zip Code
Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
Address
Same
City
State
Zip Code
Telephone Number
Draw Sketch of Area (showing two major road intersections) or Attach Map
Attached
Person Reporting Incident Jason Ricks
Company Pilot Geological, PLLC
Telephone Number 336-870-3095
Title Principal Geologist
Address PO Box 128, Kernersville, NC 27285
Date 10/26/21
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