RA-29352_48506_CA_UST-61_20220511

U5T.61 24-Hour Release and UST Leak
For Releases
in NG
This form should be completed and submitted to the UST Section's regional office following a known or suspected release fromanundergroundstoragetank(UST) system Thisformisrequiredtobesubmittedwithin24hoursofdiscoveryofaknownor
suspected release
(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 1Vltl1 f,Confirmed Soil Contamination ?(Y/N) Y
Samples Taken?(Y/N) Y
Free Producl? (Y/N) L-n[l Yes. State Greatest
Thickness
Facilitv lD Number 0-00000 l5 130
Date iea k Di ""or" rJd---OilTTZOfT
Comm/Non-Commercial? Comm
Reg/Non-regulated? Req
lncident Name: Circle K Store #Z72OyO4
INCIDENT DESCRIPTION
Address: 4835 Hope Valley Road County: Durham
City/Town: Durham I Zip Code: 27707
e one): Asheville, Mooresville, Fayetteville,
, Wilmington, Winston-Salem
Latitude (oeomat oesrees): 35.91 9270-N Longitude (deqmat desrees
Briefly describe suspected or confirmed release (including but not limited
Petroleum-impacted soil was identified during UST closure activ
HOW RELEASE WAS DISCOVERED lnereasecoael
(Check one)
lRetease Detection Equipment or Methods | flvsuauOoo, I ! Groundwater Contamination
!Sr.face Water ContaminationI During UST Closure/Removal
!eroperty Transfer
lWater in Tank
!Water Supply Well Contamination !otne, (specify)
Source of Release
(Check primary source)
[lranr
! Ripins
! Dirp"nse.
! Submersible Turbine Pump
! oetivery Problem
! spitt auctet
!otn",
! unkno*n
Definitions presented on reverse
SOURCE OF CONTAMINATION
Product Tvpe Released
(Check primary product type released)
Cause of Release
(Check primary cause)
f]spitr
! overfitt
! conosion
! Physical/Mechanical
Damage
! lnstall Problem
! otn",
ffi unkno*n
Definitions presented on reverse
Tvpe of Release
(Check one)
ff R"trot"r,
fl Non-Petroleum
! eotn
Location
(Check one)
IFacility
!Residence
!otn"'.
$Gasoline/ Diesel/
Kerosene
! Heating Oil
E otn"r Petroleum
Products
! uetats
! otner lnorganics
! other organics
! DieselA/eg Oit
Blend
! Vegetable Oil 100%
! ero - rzo
lrzr -ra+
! eas - ess
flEthanol 1oo%
! eor - eos
Ownership1 Municipal 2 Military 3 Unknown 5 Federal 6 County 7 State
Operation Tvoe'1 Public Service 2 Agricultural 3 Residential 4 EducationiRelig 5 lndustriat Mining
UST Form 61 (02/19)Page 1 of 2
Water Supply Wells Affected? .1 Yes
TER SUPPLIES
Number of Water Supply Wells Affected
Water Supply Wells
1
2.
3 -lncluae
users Names, Addresses and Numters-attacn aOOitional sheet if necessaryl
UST SYSTEM OWNER
UST Owner/ComPanY
Circle K Stores. Inc.
Address
I 100 Situs Court, Suite 100
Telephone Number
[phone]
UST SYSTEM OPERATOR
Address
ll00 Situs Couft, Suite 100
UST Operator/ComPanY
Circle K Stores, lnc.
LANDOWNER AT LOCATION OF UST INCIDENT
Address
l9l9 Wilshire Drive
Landowner
Domar Corporation, lnc.
Draw Sketch of Area (showing two major road intersections) or Attach Map
Site map attached
Date May 11,2022Address 2725 E. Millbrook Rd, Suite l2!
orm 61 (o2t1e)Page 2 ol 2
Delinitions ofSourcesTank: means the tank that stores the product and is part ofthe underground storage tank system
piping: means the piping and connectors running lrom the tank or sub]nersible turbine pump to the dispenser or other end-use equipment (vent, vapor recovery' or flll
lines are excluded )
Dispenser: includes the dispenser and the equipment used to connect the dispenser to the piping (e g, a release fiom 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 deteclor, 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 lrom 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 over;ll occurs (e.g., oueifills may occur tiom the fill pipe at the tank or when the nozzle fails to shut off at the d ispenser)
Physical or Mechanical Damage: fittlngs' broken
components, and com
Corrosion:use when a metal tank
lnstallation Problem: use when
+ cr:-r^ ^^- ^r+ha ^ lls)Other: use this option when the cause is known but does not fit lnto one ofthe p o monltorrng we
Unknown: use when the cause has not been detennined
Circle K Store #2720104
4835 Hope Valley Road
Durham, NC