MO-88910_96990_CA_UST-62_20230313

UST-62 24-Hour Notification of Discharge Form
For Non-UST
Releases of
Petroleum in NC
This form should be completed and submitted to the UST Section’s regional office following a known or suspected release of
petroleum from a source other than an underground storage tank. This form is required to be submitted within 24 hours of
discovery of a known or suspected petroleum release
(DWM USE ONLY)
Incident # ___________ Priority Rank (H,I,L,U) _____
Received (time/date) ___________________________
Received by ________________ Region __________
Reported by (circle one): 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(free product), state greatest thickness: _____feet
Release discovered
(time/date):______________
_______________________
INCIDENT DESCRIPTION
Incident Name:
Address (street number/name):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:
Describe suspected or confirmed release (nature of release, time/date of release, quantity of release, amount of free
product): GPS
Electronic topographic map
GIS Address matching
Describe initial response/abatement (time/date release stopped, cleanup begun/completed, quantity of product
soil removed, confirmation sampling):
Other
Unknown
Describe impacted receptors: Describe location:
HOW RELEASE WAS DISCOVERED (Release Code)
(Check one)
Observation of Release at Occurrence
Visual or Olfactory Evidence
Soil Contamination
Groundwater Contamination
Water Supply Well 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 petroleum product
type released)
AST (tank)
AST Piping/ Dispenser
AST Delivery Problem
OTR Vehicle Tank
OTR Bulk Transport Tank
RR Bulk Transport Tank
Transformer
Unknown
Other ______________
Definitions presented on reverse
Spill (Accidental)
Spill (Intentional)
Corrosion
Physical or Mechanical
Damage
Equipment Failure
AST Overfill
AST Installation Problem
Unknown
Other ______________
Definitions presented on reverse
Petroleum
Both Petroleum
& Non-Petroleum
Location
(Check one)
Facility
Residence
Highway/Road
Railway
Other
Gasoline/ Diesel/
Kerosene
E11 – E20
E21 – E84
E85 – E99
Ethanol 100%
Diesel/Veg. Oil
Blend
Vegetable Oil 100%
Heating Oil
Waste Oil
Mineral Oil-no
PCBs
Mineral Oil-PCBs
Other Petroleum
Products ________
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
Guidance presented on reverse
UST Form 62 (04/10) Page 1 of 2
LEGEND
Soil Sample Location
Soil/Groundwater Sample Location
Former AST locations obtained from 2005 Aerial Photo from Catawba County GIS
TMW-1/SB-1 (23 -25') (mg/kg)
Ethylbenzene - 0.0098
Xylenes - 0.035
TMW-3/SB-3 (23 - 25 ') (mg/kg)
Ethylbenzene - 0.0079
Xylenes - 0.031
TMW-3/SB-3 (ug/L)
Toluene - 2.5
Ethylbenzene - 3.6
Xylenes - 16.7
MTBE - 1.5
Naphthalene - 2.1
Isopropylbenzene - 0.73
n-Propylbenzene -1.9
n-Butylbenzene - 1
Chloromethane - 1.6
1,3,5 Trimethylbenzene - 4.4
1,2,4 Trimethylbenzene - 12.9 TMW-2/SB-2 (ug/L)
Benzene - 226
Toluene - 6,650
Ethylbenzene - 7,350
Xylenes - 40,500
MTBE - 132
Naphthalene - 2,790
Isopropylbenzene - 984
n-Propylbenzene - 1,850
n-Butylbenzene - 503
Chloromethane - < 100
1,3,5 Trimethylbenzene - 3,330
1,2,4 Trimethylbenzene - 12,100
TMW-2/SB-2 (23 - 25 ') (mg/kg)
Ethylbenzene - 8.7
Xylenes - 70.4
Naphthalene - 20.4
Isopropylbenzene - 5.2
Ethanol - 32.2
n-Butylbenzene - 6.7
p-Isopropyltoluene - 10.6
1,3,5 Trimethylbenzene - 31.6
1,2,4 Trimethylbenzene - 80.7
BOLD Results Exceed NCDEQ Soil-to-Water Maximum Soil Contaminant
Concentration (MSCC) and/or NCAC 2LGroundwater Quality StandardsSoil Concentrations in Milligrams Per Kilogram (mg/kg)Groundwater Concentrations in Micrograms Per Liter (ug/L)
Soil and Groundwater SamplesCollected on December 8, 2022
TMW-1/SB-1 (ug/L)
Benzene - 18.8
Toluene - 156
Ethylbenzene - 185
Xylenes - 840
Naphthalene - 127
Isopropylbenzene - 20.6
n-Propylbenzene -29.4
Chloromethane - 6.8
1,3,5 Trimethylbenzene - 74
1,2,4 Trimethylbenzene - 281