WS-96266_96906_CA_UST-62_20230103

UST-62 24-Hour Release and UST Leak Reporting Form.
(DWM USE ONLY)
Incident # ________ Risk (H,I,L,U)_______
Received On ________ Received By ________
Reported by: Phone, Fax or Report
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 ______________
Release Discovered
INCIDENT DESCRIPTION
Incident Name:
Address:County: Guilford
City/Town:Zip Code:Regional Office: Winston-Salem
Latitude (decimal degrees):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)
Obtained by:
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 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)
Definitions presented on reverse
Spill
Overfill
Corrosion
Physical or Mechanical Damage
Other
Unknown
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
Municipal Military Unknown Private Federal County State
Operation Type Public Service Agricultural Residential Education/Relig. Industrial Commercial Mining
UST Form 61 (02/08)Page 1 of 2
Tank
Piping
Dispenser
Submersible Turbine Pump
Delivery Problem
Other
Unknown
Definitions presented on reverse
Install Problem
Region: WS
Time/Date: _____________
ft
IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected? Yes No 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
Email Address
Guilford County, NC
Disclaimer: While every effort is made to keep information provided over the internet accurate and up-to-date, Guilford County does not certify the
authenticity or accuracy of such information. No warranties, express or implied, are provided for the records and/or mapping data herein, or for their
use or interpretation by the User.
Map Scale
1 inch = 42 feet
1/3/2023
Guilford County, NC
Disclaimer: While every effort is made to keep information provided over the internet accurate and
up-to-date, Guilford County does not certify the authenticity or accuracy of such information. No
warranties, express or implied, are provided for the records and/or mapping data herein, or for their
use or interpretation by the User.
Map Scale
1 inch = 2000 feet
1/3/2023