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Home My WebLink AboutWS-29635_48766_ CA_UST-61_20221011UST-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)T GPS T Topographic map T GIS Address matching T Other T Unknown Describe location: HOW RELEASE WAS DISCOVERED (Release Code) (Check one) T Release Detection Equipment or Methods T During UST Closure/Removal T Property Transfer T Visual/Odor T Water in Tank T Water Supply Well Contamination T Groundwater 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 product type released) TTank TPiping TDispenser TSubmersible Turbine Pump TDelivery Problem TOther TUnknown Definitions presented on reverse TSpill TOverfill TCorrosion TPhysical or Mechanical Damage TInstall Problem TOther TUnknown Definitions presented on reverse TPetroleum TNon-Petroleum TBoth Location (Check one) T Facility T Residence T Other T Gasoline/ Diesel/ Kerosene T Heating Oil T Other Petroleum Products T Metals T Other Inorganics T Other Organics T Diesel/Veg. Oil Blend T Vegetable Oil 100% T E10 – E20 T E21 – E84 T E85 – E99 T Ethanol 100% T 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 (02/08)Page 1 of 2 NA N 9/28/22 Y Comm. Y Regulated N NA Former American Heritage Automotive 4501 NC Hwy 704 Rockingham Madison 27025 -79.944976 On 9/28/2022, Pyramid supervised the removal and permanent closure of one 500-gal. gasoline UST and one 500-gal. used motor oil UST at the site .One soil sample was collected from the bottom/center of each UST basin. Soil samples were also collected beneath the product line and former gasoline dispenser. The soil sampls were shipped to Red Lab in Wilmington, NC for for laboratory analysis. The lab results of the soil samples collected beneath the USTs indicated DRO and GRO concentrations that exceed the NC DEQ action limits (see attached lab report). 36.377088 Google Earth 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 (02/08)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 Not Applicable - UST was unknown and was taken out of service many years ago. Jake Van Geison (864) 232-5491 Not Applicable - See above SC Deacons, LLC 101 East Washington Street, Suite 400 Greenville SC 29601-4815 (864) 232-5491 See attached maps Brett Higgins Pyamid Environmental & Engineering, P.C. :336-335-3174 Sr. Project Manager 503 Industrial Avenue, Greensboro, NC 10/11/22 5PQPHSBQIJD.BQ /PSUI$BSPMJOB "NFSJDBO)FSJUBHF"VUPNPUJWF .BEJTPO /$ 3PDLJOHIBN 4$%FBDPOT --$ /$)JHIXBZ .BEJTPO h 53$ #4) Mayodan, NC 2016 N/A Site Location 'JHVSF 4$%FBDPOT --$ /$)JHIXBZ .BEJTPO /PSUI$BSPMJOB "FSJBM1IPUPHSBQI 3PDLJOHIBN _JOGU h h Subject Property Smart Chevrolet Woodland Cemetery 7D[,'4$%FBDPOT --$/$)JHIXBZ.BEJTPO/PSUI$BSPMJOB"FSJBMXJUI*OJUJBM645$MPTVSF4PJM4BNQMFT53$/PUUP4DBMF#4)%FUBJMFormer 500-gal. gasoline UST Former 500-gal. Used Oil UST NC 704Soil sample collected on 9/28/22LegendFormer UST location (removed on 9/28/22)UST1-9' PL1-3' D1-3' UST2-8' Hydrocarbon Analysis ResultsClient:PYRAMIDSamples takenWednesday, September 28, 2022Address:503 INDUSTRIAL AVESamples extractedWednesday, September 28, 2022Samples analysedMonday, October 03, 2022Contact:BRETT HIGGINS OperatorTORI KELLY Project:#2022-2757U04049Matrix Sample IDDilution usedBTEX (C6 - C9)GRO (C5 - C10)DRO (C10 - C35)TPH (C5 - C35)Total Aromatics (C10-C35)16 EPA PAHsBaP HC Fingerprint Match% light % mid% heavys UST1-9' 268.0 <6.7 1334 2338 3672 145.9 5.7 <0.27 99.7 0.2 0.1Deg.Kerosene 90.2%,(FCM)s D1-3' 21.3 <0.53 <0.53 0.98 0.98 0.33 <0.17 <0.021 0 75.4 24.6Deg Fuel 89.8%,(FCM)s PL1-3' 21.8 <0.55 <0.55 <0.55 <0.55 <0.11 <0.17 <0.022 0 100 0Residual HCs UST2-8' 20.2 <0.5 11.3 151.3 162.6 9 0.95 <0.02 76.8 21 2.1Waste Oil 81.5%,(FCM)InitialCalibratorQCcheckOKFinalFCMQCCheckOK 91.5 %Results generated by a QED HC-1 analyser. Concentration values in mg/kg for soil samples and mg/L for water samples. Soil values are not corrected for moisture or stone contentFingerprints provide a tentative hydrocarbon identification. The abbreviations are:- FCM = Results calculated using Fundamental Calibration Mode : % = confidence for sample fingerprint match to library(SBS) or (LBS) = Site Specific or Library Background Subtraction applied to result : (PFM) = Poor Fingerprint Match : (T) = Turbid : (P) = Particulate presentRatios QEDHydrocarbonFingerprints Project: #2022Ͳ275 Monday,October03,2022