WS-9399_44618_CA_UST-61__20160108

UST-61
For Releases
in NC
Incident # __________Risk (H,I,L,U)
__________
Received On _________Received By ___________
Region
_______________
Incident Name:
Address:
City/Town:Zip Code:27295
Latitude (decimal degrees):
Location
(Check one)
Confirmed GW Contamination? (Y/N) _N__Date Leak Discovered ____12/14/15_____
24-Hour Release and UST Leak Reporting Form.
This form should be completed and submitted to the UST Section’s regional office following a known or suspected release froman
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)Suspected Contamination? (Y/N) _____Facility ID Number ___________________
INCIDENT DESCRIPTION
Reported by (circle one): Phone, Fax or Report Free Product? (Y/N) ______If Yes, State Greatest Reg/Non-regulated?__Non______
Thickness ______
Confirmed Soil Contamination ?(Y/N) ___Y__Comm/Non-Commercial? ____Non__
HOW RELEASE WAS DISCOVERED (ReleaseCode)
80.282646 Obtained by:
Describe location:
35.889009
Araque Property
138 Winchester Ct.County: Davidson
Lexington Regional Office (circle one): Asheville, Mooresville, Fayetteville,
Raleigh, Washington, Wilmington, Winston-Salem
Soil contamination identified during UST assessment
Longitude (decimal degrees) :
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
X Other
Unknown
SOURCE OF CONTAMINATION
Source of Release Cause of Release Type of Release Product Type Released
(Check One)
Release Detection Equipment or Methods
During UST Closure/Removal
X Property Transfer
X Visual/Odor
Water in Tank
Water Supply Well Contamination
Groundwater Contamination
Surface Water Contamination
Other (specify)
Gasoline/Diesel/Kerosene
X Heating Oil
Other Petroleum Products
Metals
Other Inorganics
Other Organics
(Source of Release)(Cause)(Type)(Ptype)
(Check one)(Check one to indicate primary
source)
(Check one to indicate primary
cause)
(Check one to indicate primary
product type released)
1. Public Service 2. Agricultural 3. Residential 4. Education/Relig. 5. Industrial 6. Commercial 7. Mining
Facility
X Residence
Other
Definitions presented on reverse Definitions presented on reverse
Ownership
X Tank
Piping
Dispenser
Submersible Turbine Pump
Delivery Problem
Other
Unknown
Spill
Overfill
X Corrosion
Physical or Mechanical
Damage
Install Problem
Other
Unknown
X Petroleum
Non-Petroleum
Both
1. Municipal 2. Military 3. Unknown 4. Private 5. Federal 6. County 7. State
Operation Type
State Telephone Number
NC [phone]
State Telephone Number
State Telephone Number
Person Reporting Incident: J. Ricks
Title: Senior Env. Scientist Date:1/8/2016
UST SYSTEM OWNER
UST Owner/Company
Lexington 27292
City Zip Code
Leonel Araque
Leonel Araque 2 N. Payne St.
UST SYSTEM OPERATOR
UST Operator/Company Address
Same
IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected? 1. Yes______ 2. No 3. Unknown___X____
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.
Address: P.O. Box 5884, Winston-Salem, NC 27113
Draw Sketch of Area (showing two major road intersections) or Attach Map
SEE ATTACHED FIGURE
Company Progress Environmental, Inc. Telephone Number: 336-722-9999
Point of Contact Address
LANDOWNER AT LOCATION OF UST INCIDENT
Same
City Zip Code
City
Landowner Address
Zip Code
ProgressENVIRONMENTAL, INC.JAB1016003.001JAN 2016JTRAS SHOWNJAN 2016Figure1.SKFP.O. Box 5884WINSTON-SALEM, NORTH CAROLINA 27113PHONE [phone] FAX [phone]FIG URE 1SITE M AP138 W IN CHESTER CO URTLEXING TO N , NO RTH CARO LINA%db("MAG-DATE")PROJECTApproximate UST Location