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Home My WebLink AboutWS-29505_48978_CA_UST-61_20220826UST-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) _____Y___ Confirmed GW Contamination? (Y/N) ___Y___ Confirmed Soil Contamination ?(Y/N) ___Y___ Samples Taken?(Y/N) ___Y___ Free Product? (Y/N) __Y_ If Yes, State Greatest Thickness ___0.04 feet___________ Facility ID Number 00-0-0000029186 Date Leak Discovered _07/28/22_ Comm/Non-Commercial? __C_____ Reg/Non-regulated? __R_________ INCIDENT DESCRIPTION Incident Name: 2022 Site Check Address: County: City/Town: Zip Code: Regional Office (circle one): 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)  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 SOURCE OF CONTAMINATION Source of Release (Check primary source) Cause of Release (Check primary cause) Type of Release (Check one) Product Type Released (Check primary product type released)  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  Unknown Definitions presented on reverse  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 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 1101 NC Highway 61 Whitsett 27377 -79.564173408687636.0634736750537 x Guilford x x x x x During a NCDEQ site inspection on Thursday July 28, 2022 it was documented that there was fuel present in soil of the new piping line trench from the gasoline dispensers to the diesel dispensers. Fuel and water were present in all but the last diesel dispenser sump. A notice of violation letter was issued on Friday July 29, 2022. Violations were immediately addressed by removing fuel and stained soil and gravel, and tightness testing the USTs and piping. The USTs and piping passed the tightness tests. Site check sampling was completed in August and included sampling of soil and groundwater around the new piping trench field. Investigations indicate the location of fuel overlaps areas of past release that is being addressed by ongoing remediation. Soil results indicated TPH-DRO greater than 100 mg/kg and EPH greater than the soil to groundwater standards, but less than the Industrial/ Commercial Soil Cleanup Levels. Groundwater results indicated only benzene and lead were greater than the groundwater quality standards. The site is connected to public water. Potable off site wells are monitored as part of the ongoing remediation. Results of the potable well sampling are submitted to NCDEQ on a regular basis. Other (specify) X IMPACT ON DRINKING WATER SUPPLIES 3.UnknownWater Supply Wells Affected? 1. Yes 2. No 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 (02/19) 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 HPT TA Properties Trust 24601 Center Ridge Road, Westlake OH 44145 Rob Porges 440-808-7368 TA Operating LLC 440-808-7368WestlakeOH 44145 24601 Center Ridge Road, HPT TA Properties Trust Westlake OH 44145 440-808-7368 See attached figure 1. Rob Porges TA Operating LLC 24601 Center Ridge Road, , Westlake, OH 44145 08/26/2022 440-808-7368 24601 Center Ridge Road, Esri, HERE, Garmin, (c) OpenStreetMap contributors, Source: Esri,DigitalGlobe, GeoEye, Earthstar Geographics, CNES/Airbus DS, USDA,USGS, AeroGRID, IGN, and the GIS User Community ³ Coordinate System: NAD 1983 StatePlane North Carolina FIPS 3200 FeetDocument Path: J:\TA\TA Greensboro\Maps\Fig2-Site Map.mxdfigure: approved: checked: drawn: TravelCenters of America 1101 NC Highway 61, Whitsett, NC Site Map NLB 08/26/22 Legend 1500-foot Radius from USTs Property Boundary 2-ft Topographic Contour 500 0 500250 Feet Greensboro, NC 44145 1 1 inch = 500 feet UST System Diesel Dispensers Gasoline Dispensers Notes:Topographic contours downloaded from:https://services.nconemap.gov/ncom-contours-dd.htm