WS-29078_48266_CA_UST-61_20211214

UST-61 24-Hour Release and UST Leak Reporting Form.
For Releases 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 in NC 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) Y Confirmed GW Contamination? (Y/N) N Confirmed Soil Contamination ?(Y/N) Y Samples Taken?(Y/N) Y Free Product? (Y/N) N If Yes, State Greatest Thickness NA
Facility ID Number 0-0-23995 Date Leak Discovered 12-14-21 Comm/Non-Commercial? Comm Reg/Non-regulated? Reg
INCIDENT DESCRIPTION
Incident Name: Mountain Top Quick Stop
Address: 1224 US Hwy 21 South County: Alleghany
City/Town: Sparta Zip Code: 28675 Regional Office (circle one): Asheville, Mooresville, Fayetteville, Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): 36.493987o Longitude (decimal degrees) : -81.106093o Obtained by:
GPS
Topographic map
GIS Address matching
X Other
Unknown
Describe location:
Google Earth location
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) During excavation and removal of one 10,000-gallon and two 6,000-gallon gasoline USTs, and
one 4,000-gallon diesel fuel UST, contaminated soils above and around the USTs were noted.
On-site testing of samples of excavated soils by ultra-violet fluorescence indicated
concentrations of TPH-GRO and DRO that exceeded the respective action levels of 50 mg/kg
and 100 mg/kg.

HOW RELEASE WAS DISCOVERED (Release Code)
(Check one)
Release Detection Equipment or Methods
X 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 Cause of Release Type of Release Product Type Released
(Check primary source) (Check primary cause) (Check one) (Check primary product type released)
X Tank
 Piping
 Dispenser
 Submersible Turbine Pump
 Delivery Problem
 Spill Bucket
Other
 Unknown
Definitions presented on reverse
 Spill
 Overfill
 Corrosion
 Physical/Mechanical
Damage
 Install Problem
 Other
X Unknown
Definitions presented on reverse
X Petroleum
 Non-Petroleum
 Both
Location
(Check one)
X Facility
Residence
Other

X Gasoline/ Diesel/  Diesel/Veg. Oil
Kerosene Blend
 Heating Oil  Vegetable Oil 100%
 Other Petroleum E10 – E20
Products E21 – E84
 Metals E85 – E99
 Other Inorganics Ethanol 100%
 Other Organics 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 (02/19) Page 1 of 2
IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected? 1. Yes 2. No 3. Unknown
Number of Water Supply Wells Affected Unknown
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 J. Gwyn Gambill, Inc.
Point of Contact James G. Gambill, JR. Address 681 Beaver Creek School Road West
City Jefferson State NC Zip Code 28694-7117 Telephone Number 336-846-5401
UST SYSTEM OPERATOR
UST Operator/Company J. Gwyn Gambill, Inc. Address 681 Beaver Creek School Road West
City Jefferson State NC Zip Code 28694-7117 Telephone Number 336-846-5401
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner James Joseph Boyer Address 1224 US Highway 21 South
City Sparta State NC Zip Code 28675 Telephone Number 336-657-1937
Draw Sketch of Area (showing two major road intersections) or Attach Map See Attached Map
Person Reporting Incident: Brian Bellis, P.G. Company: WithersRavenel, Inc. Telephone Number: 919-469-3340
Title: Project Manager Address: 115 MacKenan Drive, Cary, NC 27511 Date: 12-14-21
UST Form 61 (02/19) 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