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Home My WebLink AboutRA-29471_48615_CA_UST-61_20220803 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) ________ Confirmed GW Contamination? (Y/N) ______ Confirmed Soil Contamination ?(Y/N) ______ Samples Taken?(Y/N) ______ Free Product? (Y/N) _____ If Yes, State Greatest Thickness ______________ Facility ID Number ______________ Date Leak Discovered ___________ Comm/Non-Commercial? ________ Reg/Non-regulated? _____________ INCIDENT DESCRIPTION Incident Name: Address: 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: 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  GIS Address matching  Other  Unknown Describe location: HOW RELEASE WAS DISCOVERED (Release Code) (Check one)  Release Detection Equipment or Methods  During UST Closure/Removal  Property Transfer  Visual/Odor  Water in Tank  Water Supply Well 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)  Tank  Piping  Dispenser  Submersible Turbine Pump  Delivery Problem  Spill Bucket  Other  Unknown Definitions presented on reverse  Spill  Overfill  Corrosion  Physical/Mechanical Damage  Install Problem  Other  Unknown Definitions presented on reverse  Petroleum  Non-Petroleum  Both Location (Check one)  Facility  Residence  Other  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 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 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 Summary of Detected Analytes QualifiersAnalyzedUnitsResult Report Number: Client Sample ID Method Parameters Lab Sample ID 22-189-0051 Report Limit Project:Flash Market #370 V 93939MW-1 54.5 07/14/2022 23:346200BAcetoneµg/L 1.80 99.2 07/14/2022 23:346200BBenzeneµg/L 0.180 2.86 07/14/2022 23:346200Bn-Butylbenzene µg/L 0.180 1.35 07/14/2022 23:346200Bsec-Butyl benzene µg/L 0.200 5.59 07/14/2022 23:346200BDi-Isopropyl Ether (DIPE)µg/L 0.500 J66.7 07/14/2022 23:346200BEthanolµg/L 42.0 40.9 07/14/2022 23:346200BEthylbenzeneµg/L 0.170 J0.829 07/14/2022 23:346200BEthyl Tertiary Butyl Ether (ETBE)µg/L 0.059 5.24 07/14/2022 23:346200B2-Hexanone µg/L 0.380 6.89 07/14/2022 23:346200BIsopropylbenzeneµg/L 0.180 0.826 07/14/2022 23:346200B4-Isopropyl toluene µg/L 0.089 23.7 07/14/2022 23:346200BMethyl Ethyl Ketone (MEK)µg/L 0.710 3550 07/15/2022 18:146200BMethyl tert-butyl ether (MTBE)µg/L 14.0 3.78 07/14/2022 23:346200B4-Methyl-2-Pentanone µg/L 0.078 8.01 07/14/2022 23:346200BNaphthaleneµg/L 0.470 11.0 07/14/2022 23:346200Bn-Propylbenzene µg/L 0.190 2640 07/15/2022 18:146200Btert-Butyl Alcohol (TBA)µg/L 160 1210 07/15/2022 18:146200Btert-Amyl Alcohol (TAA)µg/L 190 69.0 07/14/2022 23:346200Btert-Amyl Methyl Ether (TAME)µg/L 0.280 40.0 07/14/2022 23:346200BTolueneµg/L 0.220 95.7 07/14/2022 23:346200B1,2,4-Trimethylbenzene µg/L 0.190 26.4 07/14/2022 23:346200B1,3,5-Trimethylbenzene µg/L 0.180 66.9 07/14/2022 23:346200Bo-Xylene µg/L 0.210 143 07/14/2022 23:346200Bm,p-Xylene µg/L 0.420 210 07/14/2022 23:346200BXylene (Total)µg/L 0.210 846 07/14/2022 23:34CALCULATIONAliphatic C5-C8 (Adjusted)µg/L 115 164 07/14/2022 18:59CALCULATIONAliphatics C9-C12 (Adjusted)µg/L 25.8 308 07/14/2022 18:59CALCULATIONAromatic C9-C10 (Adjusted)µg/L 4.02 985 07/15/2022 08:41MADEP-VPH Aliphatic C5-C8 µg/L 115 723 07/14/2022 18:59MADEP-VPH Aliphatic C9-C12 µg/L 25.8 308 07/14/2022 18:59MADEP-VPH Aromatic C9-C10 µg/L 4.02 V 93940SB-1-10' 0.200 07/12/2022 14:008260DAcetonemg/Kg - dry 0.003 J0.002 07/12/2022 14:008260DBenzenemg/Kg - dry 0.0008 J0.002 07/12/2022 14:008260DBromomethanemg/Kg - dry 0.002 J0.002 07/12/2022 14:008260DCarbon Disulfide mg/Kg - dry 0.0009 Page 4 of 50 Disclaimer iMaps makes every effort to produce and publishthe most current and accurate information possible. However, the maps are produced for information purposes,and are NOT surveys. No warranties, expressed or implied ,are provided for the data therein, its use,or its interpretation. 25 100 ft500 ± PARCEL_PK: 118995 REID: 0232220 PIN_NUM: 0754615887 PIN_EXT: 000 LAND_VAL: 822236 BLDG_VAL: 844621 TOTAL_VALUE_ASSD: 1666857 DEED_ACRES: 1.32 TOTSALPRICE: 1300000 SALE_DATE: 10/8/2021 YEAR_BUILT: 1997 HEATEDAREA: 2868 TYPE_AND_USE: 46 TYPE_USE_DECODE: CONV STORE DESIGNSTYL: CVL DESIGN_STYLE_DECODE: Conventional CITY: CAR CITY_DECODE: CARY PLANNING_JURISDICTION: CA TOWNSHIP: 04 TOWNSHIP_DECODE: Cary OWNER: GETTY LEASING INC ADDR1: 292 MADISON AVE FL 9 ADDR2: NEW YORK NY 10017-6376 DEED_BOOK: 018765 DEED_PAGE: 01681 DEED_DATE: 10/26/2021 LAND_CODE: C LAND_CLASS: COM LAND_CLASS_DECODE: Commercial OWNERSHIP: 1020 ACTIVITY: 2110 FUNCTION: 2152 STRUCTURE: 2591 FM #370 1 inch equals 50 feet Property