WS-10202_45327_CA_UST-61_20200117

UST-61
For Releases
in NC
Incident # __________Risk (H,I,L,U)
__________
Received On _________Received By ___________
Region _______________
Incident Name:
Address:
City/Town:Zip Code:27104
Latitude (decimal degrees):
Location
(Check one)
1. Public Service 2. Agricultural 3. Residential 4. Education/Relig. 5. Industrial 6. Commercial 7. Mining
X Facility
Residence
Other
Definitions presented on reverse Definitions presented on reverse
Ownership
X Tank
Piping
Dispenser
Submersible Turbine Pump
Delivery Problem
Other
Unknown
1. Municipal 2. Military 3. Unknown 4. Private 5. Federal 6. County 7. State
Operation Type
(Check one to indicate primary
cause)
(Check one to indicate primary
product type released)
Spill
Overfill
Corrosion
Physical or Mechanical
Damage
Install Problem
Other
X Unknown
X Petroleum
Non-Petroleum
Both
Release Detection Equipment or Methods
During UST Closure/Removal
X Property Transfer
X Visual/Odor
Water in Tank
Water Supply Well Contamination
X Gasoline/Diesel/Kerosene
Heating Oil
Other Petroleum Products
Metals
Other Inorganics
Other Organics
(Source of Release)(Cause)(Type)(Ptype)
(Check one)(Check one to indicate primary
source)
3398 Robinhood Road County: Forsyth
Winston-Salem Regional Office (circle one): Asheville, Mooresville, Fayetteville,
Raleigh, Washington, Wilmington, Winston-Salem
SOURCE OF CONTAMINATION
Source of Release Cause of Release Type of Release Product Type Released
(Check One)
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
Soil contamination discovered following the completion of a site check
HOW RELEASE WAS DISCOVERED (ReleaseCode)
Groundwater Contamination
Surface Water Contamination
Other (specify)
Comm/Non-Commercial? ___Commerical__
Describe location:
36.116380 Longitude (decimal degrees) :
If Yes, State Greatest Reg/Non-regulated?__Regulated______
Thickness ______
Confirmed GW Contamination? (Y/N) N
80.314356 Obtained by:
Reported by (circle one): Phone, Fax or Report Free Product? (Y/N) ______
Date Leak Discovered ___2/4/20______
INCIDENT DESCRIPTION
Quality Mart #18
Confirmed Soil Contamination ?(Y/N) ___Y__
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) ___Y__Facility ID Number 00-0-000015212
State Telephone Number
NC 33-722-3441
State Telephone Number
NC 336-722-3441
State Telephone Number
NC 336-722-3441
Person Reporting Incident: J. Ballsieper
Title: Director of Env. Serv.Date:2/4/2020
City Zip Code
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 Group, Inc. Telephone Number: 336-722-9999
Winston-Salem 27102
Address
Winston-Salem 27102
1540 Silas Creek Parkway
LANDOWNER AT LOCATION OF UST INCIDENT
UST Operator/Company Address
Quality Oil Company, LLC
City Zip Code
Point of Contact Address
Quality Oil Company, LLC 1540 Silas Creek Parkway
City Zip Code
Winston-Salem 27102
UST SYSTEM OPERATOR
Landowner
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)
John Shutt 1540 Silas Creek Parkway
1.
2.
3.
UST SYSTEM OWNER
UST Owner/Company
Quality Oil Company, LLC
ProgressENVIRONMENTAL GROUP, INC.JSL1020024.001FEBRUARY 2020JABAS SHOWNFEBRUARY 2020Figure 2.SKFP.O. Box 5884WINSTON-SALEM, NORTH CAROLINA 27113PHONE [phone] FAX [phone]FIGURE 1SITE MAPQUALITY MART #183398 ROBINHOOD ROADWINSTON-SALEM, NORTH CAROLINAPROJECTS-1
CURRENT UST LOCATION
APPROXIMATE LOCATION OF SOIL SAMPLE
S-1
S-2