FA-29711_48876_CA_UST 61_20230208

24-Hour Release and UST Leak R*pofting Form.
FOr ReleaSes This form shoutd be compteted a
an underground storage tank (UST) system. This form is required to be submitted within-24 hours of discovery of a known or
(DWM USE ONLY)
lncident # Risk (H,|,L,U)_
Received On _ Received By _Reported by (circle one): Phone, Fax or Report
Region
Suspected Contamination? (Y/N) Y
Confirmed GW ContaminationZ 1V7g _N-Confirmed Soil Contamination ?(y/N) Y
Samples Taken?(Y/N) Y
Free Product? (Y/N) N lf Yes, State Greatest
Thickness
Facility lD Number 00-0-000001 1 304
Date Leak Discovered 02108/2023
Comm/Non-Commercial?-- Coln m-RegiNon-regulated? Res-
INCIDENT DESCRIPTIONlncident Name: 61..1. K Store #2i23022
Address: 2326 Owen Drive
city/Town: Fayeueville ] zio cooe, ,*rou
Olfice (circle one): Asheville,
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (oecimar oesrees): 35.01915 N Longitude (oecimar oesrees) : 78.91676W Obtained by:
!ees
!Topographic map
fficts eddress matching
flotne,
!untnornn
Describe location:
describe suspected or confirmed rel
ase, amount of free product present aN recovery effofts, initiat responset conducted, impacts to receptors)
ts to soil were noted during UST closure activities.
HOW RELEASE WAS DISCOVERED lnereasecoae)
, (Check one)
f]Visuat/odor
lwater in Tank
[Water Supply Well Contamination
IRebare Detection Equipment or Methods
ffi Ouring UST Closure/Removat
Ieroperty Transfer
OF CONTAMINATION
Tvpe of Release
(Check one)
I Petrot"r,
! Non-Petroteum
I aotr
Location
(Check one)
IFacitity
IResidence
!otnet
Source of Release
(Check primary source)
! rant
! nipins
I Dirpentet
! Submersible Turbine pump
! oetirery probtem
! spitt aucxet
!orne,
E unkno*n
Espirr
! Overfitt
! Corrosion
! Physicat/Mechanicat
Damage
f] lnstatt Probtem
! otne,
ffi unxno*n
Definitions presented on rcverse
I Gasoline/ Dieset/
Kerosene
! Heating Oit
! otne, Petroteum
Products
I uetats
I otner lnorganics
! Otnu, Organics
! DieselA/eg. Oit
Blerd
I Vegetable Oit 100o/o
I ero - rzo
E ezr - eaa
I ras - ess
I Ethanot 100o/o
I eor - eos
SOURCE
Gaqqe of Release
(Check primary cause)
[e-mail]
1.PublicService2.AgricUltural3.Residential4.Education/Relig.5.lndUStrial@'Mining
usr-6{
IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected? 1. Yes 3.Unknown
Number of Water SupplyWells Affected
Water Supply Wells Contaminated: (lnclude Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
't.
2.
3.
UST SYSTEM OWNER
UST Owner/Company
Circle K Stores, lnc.
Point of Contac{
Alan Cubberley
Address
I 100 Situs Court. Suite 100
Cily
Raleigh
State
NC
Zip Code
27606
Telephone Number
(9t0) 774-6700
UST SYSTEM OPERATOR
UST Operator/Company
Circle K Stores. Inc.
Address
I100 Situs Court. Suite 100
City
Raleigh
State
NC
Zip Code
27606
Telephone Number
[phone]
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
McCauley and McDonald Investments, lnc.
Address
P.O. Box 361
Fayetteville
State
NC
Zip Code
28302
Telephone Number
Unknown
Draw Sketch of Area (showing two major road intersections) or Attach Map
Site map attached
PersonReportinglncidentMJackson.PG|CompanYATCAssociatesofNConb.t.:tll
Title Sr. Project Manager Address 2725E.Millbrook Road, Suite l2l Raleigh, NC 27604 | Date p.6n uo 3,2623
UST 1 (02/19)Page
Dcfinitions of SourcesTank: means the tank that stores the product and is part ofthe underground storage tank systemPiping: means the piping and connectors runhing from the tank or submersible turbine pump to the dispenser or other end-use equtpment (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 submprsible 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 delrvery to the tank. (Typical causes associated wrth 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 ofthe precedrng categories (e.g., fbr releases from vent lines, vapor
recovery lines, and fill lines)
Unknown: identifies releases for which the source has not been determined
Definitions ofCausesSpill: 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 offat the dispenser)
Physical or Mechanical Damage: use for all types ofphysical or mechanical damage. except corrosion (e.g., puncture oftank or piping, loose fittings, broken
components, and components that have changed dimension)
Conosion. use when a metal tank, piping, or other component has a release due to corrosion (e.g., lbr steel, corrosion takes the form ofrust)
lnstallationProblem: usewhentheproblemisdeterminedtohaveoccurredspecificallybecausetheUSTsystemwasnotinstalledproperlyOther: use this option when the cause is known but does not fit rnto one of the preceding categories (e.g.. putting regulated substances into monitoring wells)
Unknown: use when the cause has not been determined
CARWASHCIRCLE K#2723022STOREUSTBASINDISPENSERCANOPYOWEN DRIVECUMBERLAND ROAD