RA-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
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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