MO-28833_48049_CA_UST-61_20210929_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
Incident # Risk (H,I,L,U)
Confirmed GW Contamination? (Y/N)
Date Leak Discovered
Received On Received By
Confirmed Soil Contamination ?(Y/N)
Comm/Non-Commercial?
Reported by (circle one): Phone, Fax or Report
Samples Taken?(Y/N)
Reg/Non-regulated?
Region
Free Product? (Y/N) If Yes, State Greatest
Thickness
INCIDENT DESCRIPTION
Incident Name:
Address:
County:
Regional Office (circle one): Asheville, Mooresville, Fayetteville,
City/Town:
Zip Code:
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 present and recovery efforts, initial responses conducted, impacts to receptors)
❑Topographic map
❑GIS Address matching
❑Other
❑ Unknown
Describe location:
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
❑ Dispenser
❑Heating Oil ❑ Vegetable Oil 100%
Corrosion Both
❑❑
❑ Other Petroleum ❑ E10 - E20
❑ Submersible Turbine Pump
❑Physical/Mechanical
❑ Delivery Problem
Location Products
Damage ❑ E21 - E84
(Check one) Metals
❑
❑ Install Problem ❑ E85 - E99
❑ Spill Bucket
❑ Other Inorganics
❑ Other [-]Facility ❑Ethanol 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.
Residential 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 3. Unknown
Number of Water Supply Wells Affected
Water Supply Wells Contaminated:
1.
2.
3.
(Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
UST Owner/Company
UST SYSTEM OWNER
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
City
State
Zip Code
Telephone Number
Draw Sketch of Area (showing two major road intersections) or Attach Map
Person Reporting Incident
Company
Telephone Number
Title
Address
Date
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

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jAPPROVED BY: DRAWN BY: Mecklenburg Co.
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SEDGEFIELD PARCEL B
CHARLOTTE, NORTH CAROLINA
FIGURE NUMBER:
TAX LINE MAP CH14.017-2

Beverly, Trudy
From: Beverly, Trudy
Sent: Wednesday, September 29, 2021 1:54 PM
To: Tom Hassett
Subject: RE: [External] [Not Virus Scanned] Heating oil UST - 2807 South Boulevard
Hey Tom,
Documentation received. No need to send a paper nor a cd. I will let you know if I have questions.
Have a great day,
Trudy
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 everlyL&ncdenn 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://deq.nc.gov/about/divisions/waste-manaaement/ust
Branch's Above Ground Storage Tanks Website Address: hgps://deg.nc.gov/about/divisions/waste-management/ust/ast-prosram
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httns://deo.nc. eov/about/divisions/waste-management/waste-management-rules-data/waste-management-eis-maps
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):
hit 2s://deg.nc.gov/about/divisions/waste-management/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
httys:Hfiles.nc.aov/nedeci/Waste%2OMana2ement/DWM/UST/WhatsNew/Final-Electronic-Document-Submittal-Policy.odf
htips:Hfiles.nc. gov/ncdeq/\Vaste%2OManagement/D WMiUST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx
From: Tom Hassett[mailto:[e-mail]]
Sent: Wednesday, September 29, 2021 1:43 PM
To: Beverly, Trudy <[e-mail]>
Subject: [External] [Not Virus Scanned] Heating oil UST - 2807 South Boulevard
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
-iis message contains an attachment that was NOT virus scanned and could be
ou are receiving a file from an unknown source, please forward the email as an
attachment to
Trudy,
or contact the DIT Service Desk at 919-754-60

We were finalizing a Phase I ESA for a property in Charlotte and I did not see the site on the LUST database. We
previously monitored the removal of a heating oil tank (associated with a former boiler), but the closure documentation
apparently never made it to DEQ.
Therefore, I am attaching a UST-61 form and the closure report as our client has asked us to get the incident
resolved. Would you need me to send paper copies and CDs by mail?
We left soils in place that exceed residential, but not industrial/commercial, MSCCs. However we found no receptors
that would elevate the Risk category, so believe that the incident can be closed. We are putting together a NORR for the
owner and will forward that when signed.
Thank you,
Tom
Thomas C. Hassett, P.E.
Senior Engineer
GEOSCIENCE GROUP, INC.
500-K Clanton Road
Charlotte, NC 28217
[phone] - Office
[phone] - Fax
[phone] - Mobile