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HomeMy WebLinkAboutMO-88902_96916_CA_UST-62_20221228 UST-62 24-Hour Notification of Discharge Form For Non-UST Releases of Petroleum in NC This form should be completed and submitted to the UST Section’s regional office following a known or suspected release of petroleum from a source other than an underground storage tank. This form is required to be submitted within 24 hours of discovery of a known or suspected petroleum release (DWM USE ONLY) Incident # ___________ Priority Rank (H,I,L,U) _____ Received (time/date) ___________________________ Received by ________________ Region __________ Reported by (circle one): Phone, Fax or Report Suspected Contamination? (Y/N) ___ Confirmed GW Contamination? (Y/N) ___ Confirmed Soil Contamination ?(Y/N) ___ Samples taken?(Y/N) ___ Free product? (Y/N) ___ If Yes(free product), state greatest thickness: _____feet Release discovered (time/date):______________ _______________________ INCIDENT DESCRIPTION Incident Name: Address (street number/name): County: City/Town: Zip Code: Regional Office (circle one): Asheville, Mooresville, Fayetteville, Raleigh, Washington, Wilmington, Winston-Salem Latitude (decimal degrees): Longitude (decimal degrees) : Obtained by: Describe suspected or confirmed release (nature of release, time/date of release, quantity of release, amount of free product): T GPS T Electronic topographic map T GIS Address matching Describe initial response/abatement (time/date release stopped, cleanup begun/completed, quantity of product soil removed, confirmation sampling): T Other T Unknown Describe impacted receptors: Describe location: HOW RELEASE WAS DISCOVERED (Release Code) (Check one) T Observation of Release at Occurrence T Visual or Olfactory Evidence T Soil Contamination T Groundwater Contamination T Water Supply Well Contamination T Surface Water Contamination T Other (specify) _______________ SOURCE OF CONTAMINATION Source of Release (Check one to indicate primary source) Cause of Release (Check one to indicate primary cause) Type of Release (Check one) Product Type Released (Check one to indicate primary petroleum product type released) T AST (tank) T AST Piping/ Dispenser T AST Delivery Problem T OTR Vehicle Tank T OTR Bulk Transport Tank T RR Bulk Transport Tank T Transformer T Unknown T Other ______________ Definitions presented on reverse T Spill (Accidental) T Spill (Intentional) T Corrosion T Physical or Mechanical Damage T Equipment Failure T AST Overfill T AST Installation Problem T Unknown T Other ______________ Definitions presented on reverse T Petroleum T Both Petroleum & Non-Petroleum Location (Check one) T Facility T Residence T Highway/Road T Railway T Other T Gasoline/ Diesel/ Kerosene T E11 – E20 T E21 – E84 T E85 – E99 T Ethanol 100% T Diesel/Veg. Oil Blend T Vegetable Oil 100% T Heating Oil T Waste Oil T Mineral Oil-no PCBs T Mineral Oil-PCBs T Other Petroleum Products ________ 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 UST Form 62 (04/10) Page 1 of 2 426 Brookhill Road Charlotte 28203 Mecklenburg 426 Brookhill AST 35.2088149 -80.8678434 Y NY N An approximate 50-gallon residential #2 heating oil AST fell over in strong winds on Sunday, December 25, 2022 at Charlotte Fire Department arrived on-site at approximately 1700 and righted the tank to stop the spill. First Call Environmental arrived at 2015 to begin initial cleanup. Absorbant pads were deployed at the spill site, and oil absorbant granules were used on the oil flow path along the parking lot. X X N 12/25/22 @ 1645 No receptors were impacted. X X X X X Blown over by strong wind approximately 1700. According to the tennant, the AST was approximately half full at the time of the incident, and approximately 15 gallons of fuel oil remained in the tank following the spill. It is estimated that approximately 20 gallons of #2 fuel oil was released. 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 owner/ operator) Name of Person/Company Address City State Zip Code Telephone Number AST SYSTEM OWNER (if the source of the release is an AST system) AST Owner/Company Address City State Zip Code Telephone Number AST SYSTEM OPERATOR (if the source of the release is an AST system) UST Operator/Company Address City State Zip Code Telephone Number LANDOWNER AT LOCATION OF INCIDENT Landowner 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 Company Telephone Number Title Address Date UST Form 62 (04/10) 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 nozzle 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 North Carolina Brookhill Investments, LLC North Carolina Brookhill Investments, LLC North Carolina Brookhill Investments, LLC North Carolina Take Exit 7 from I-77 and head east towards S Tryon Street. Head north on S Tryon Street and turn left after Brookhill Road immediatelyopposite of Dunavant Street. The spill site is approximately 200 ft down the driveway on the left. Brandt Kayser, PG Griffin Brothers Leasing, LLC 19109 W Catawba Ave, Suite 110 914-844-7048 12/28/22 409 Basin Street Charlotte 28203 703-376-5052 703-376-5052 703-376-5052 703-376-5052 409 Basin Street 409 Basin Street 409 Basin Street 28203 28203 28203 Charlotte Charlotte Charlotte Environmental Compliance Officer Brookhill Investments, LLC TITLE PROJECT SPILL LOCATION MAP Brookhill Investments, LLC 462 Brookhill Road,Charlotte,NC 28203 DATE:FIGURE 112/28/22 Approximate 50-gallon #2 Heating Oil AST 0 100 200 APPROXIMATE SCALE IN FEET N 19109 W Catawba Ave Suite 110 Cornelius, NC 28031 914-844-7048 (p) Spill Location and Surface Flow