The URL can be used to link to this page

Home My WebLink AboutFA-29604_48735_CA_UST-61_20221017 UST-61 24-Hour Release and UST Leak Reporting Form. For Releases in NC 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 suspected release (DWM USE ONLY) Incident # ________ Risk (H,I,L,U)_______ Received On ________ Received By ________ Reported by (circle one): Phone, Fax or Report Region _______ Suspected Contamination ? (Y/N) _Y______ Confirmed GW Contamination ? (Y/N) _N___ Confirmed Soil Contamination ?(Y/N) _Y___ Samples Taken?(Y/N) ___Y___ Free Product? (Y/N) ___N__ If Yes, State Greatest Thickness ______________ Facility ID Number _None Date Leak Discovered _6-2022___ Comm/Non-Commercial ? Non-Com Reg/Non-regulated? _ Non-Reg_____ INCIDENT DESCRIPTION Incident Name: A&M Farms Address: 543 Johnson Farm Road County: Harnett City/Town: Lillington Zip Code: 27546 Regional Office (circle one): Asheville, Mooresville, Fayetteville, Raleigh, Washington, Wilmington, Winston-Salem Latitude (decimal degrees): N 35.4143027 Longitude (decimal degrees) : W -78.7589350 Obtained by: 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)  GPS  Topographic map X GIS Address matching  Other  Unknown Describe location: HOW RELEASE WAS DISCOVERED (Release Code) (Check one)  Release Detection Equipment or Methods During UST Closure/Removal PXhase II ESA for Property Transfer Visual /Odor  Water in Tank  Water Supply Well Contamination SX oil Contamination Groundwater Contamination  Surface Water Contamination  Other (specify) ___________ SOURCE OF CONTAMINATION Source of Release (Check primary source) Cause of Release (Check primary cause) Type of Release (Check one) Product Type Released (Check primary product type released) X Tank  Piping Dispenser  Submersible Turbine Pump  Delivery Problem  Spill Bucket  Other Unknown Definitions presented on reverse  Spill Overfill X Corrosion  Physical/Mechanical Damage  Install Problem  Other Unknown Definitions presented on reverse PetroleumX  Non-Petroleum  Both Location (Check one) Facility Residence X Other X Gasoline / Diesel/ Kerosene Heating Oil  Other Petroleum Products  Metals  Other Inorganics  Other Organics  Diesel/Veg. Oil Blend  Vegetable Oil 100%  E10 – E20  E21 – E84  E85 – E99  Ethanol 100%  E01 – E09 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 A Phase II Environmental Site Assessment (ESA) was completed for the USTs during June 2022 for sale of the property il Three test borings and one temporary well were completed . Soil samples from one boring showed GRO at a level with East Coast Environmental PA to remove the tanks and complete an Initial Abatement Action Report during .September and October 2022. of 172 mg/kg. Groundwater sample had low detections all below 15A NCAC 2L 0202 . A&M Farms contracted Two 550-gallon farm USTs (gasoline and diesel) were discovered while completing a Phase I ESA. 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:A& M Farms Point of Contact: Glen Johnson Address: P.O. Box 69 City: Lillington State: NC Zip Code: 27546 Telephone Number UST SYSTEM OPERATOR UST Operator/Company: Unknown/deceased Address: City: State: Zip Code: Telephone Number LANDOWNER AT LOCATION OF UST INCIDENT Landowner: A&M Family Farms, Inc. Address: 543 Johnson Farm Road City: Lillington State: NC Zip Code: 27546 Telephone Number Draw Sketch of Area (showing two major road intersections) or Attach Map Person Reporting Incident Tom Will Company East Coast Environmental, PA Telephone Number 919-772-0268 Title Geologist Address 3815 Junction Boulevard, Raleigh, NC 27603 Date 10-17-22 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 910-893-9693 910-893-6963 East Coast Environmental, P.A. 3815 Junction Boulevard Raleigh, North Carolina 27603 (919) 349-5969 Figure 1 Site Location Map A&M Farms 543 Johnson Farm Road Lillington, Harnett County, NC Scale:Prep. By:Rev. By:Date: NTS TRW TRW 10/10/2022 N Site Location Source: USGS Lillington NC Quandrangle 2022 East Coast Environmental, P.A. 3815 Junction Boulevard Raleigh, North Carolina 27603 (919) 349-5969 Figure 2 Former UST Locations A&M Farms 543 Johnson Farm Road Lillington, Harnett County, NC Scale:Prep. By:Rev. By:Date: NTS TRW TRW 10/10/2022 N Approximate Representation of Figure 3 Source: Google Earth Former UST Locations East Coast Environmental, P.A. 3815 Junction Boulevard Raleigh, North Carolina 27603 (919) 349-5969 Figure 3 Site Map With Petroleum Contaminated Soil Excavation A&M Farms 543 Johnson Farm Road Lillington, Harnett County, NC Scale:Prep. By:Rev. By:Date: 1” = 5'TRW TRW 10/10/2022 N P-1 South P-2 S-2 4' T-1 P-1 6' P-1 8' P-1 South B T-1 S-5 11' P-1 North T-1 P-1 2' P-1 6' P-1 7' P-1 S-1 9' T-1 East Sidewall P-1 East T-1 S-1 7' T-1 S-2 10' T-1 S-3 8' T-1 S-4 10' - Indicates Soil Sample Result Above GRO/DRO Action Levels Approximate Extent of Petroleum Contaminated Soil Excavation 10' x 8' x 11' deep Barn Former 550 Gallon Gasoline UST (T-1) and Product Dispenser Locations - Indicates Soil Sample Result Below GRO/DRO Action Levels T-2 S-2 P-2 S-1 2' Former 550 Gallon Diesel UST (T-2) and Product Dispenser Locations T-1 South Sidewall T-1 North Sidewall T-1 West Sidewall T-2 S-1 Approximate Location of Temporary Well Installed by S&EC during June 2022 East Coast Environmental, P.A. 3815 Junction Boulevard Raleigh, North Carolina 27603 (919) 349-5969 Figure 4 Receptor Information A&M Farms 543 Johnson Farm Road Lillington, Harnett County, NC Scale:Prep. By:Rev. By:Date: NTS TRW TRW 10/10/2022 N 5 0 0 -f o o t R a d i u s 1,000-foot Radius On-Site Well L a n d S u r f a c e S lo p e