WS-96300_97004_CA_UST-62_20230406

UST-62 24-Hour Notification of Discharge Form
For Non-UST This form should be completed and submitted to the UST Section’s regional office following a known or suspected release of
Releases 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 Petroleum in NC

(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) Y
Confirmed GW Contamination? (Y/N) N Confirmed Soil Contamination ?(Y/N) Y
Samples taken?(Y/N) N Free product? (Y/N) N
If Yes(free product), state greatest thickness: feet

Release discovered:
(time/date): 7:30 AM, 4-6-2023
INCIDENT DESCRIPTION
Incident Name: Ames Construction
Address (street number/name): 5938 Julian Airport Rd County: Randolph
City/Town: Liberty Zip Code: NC Regional Office (circle one): Asheville, Mooresville, Fayetteville,
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): 35.8909025 Longitude (decimal degrees) : -79.6302953 Obtained by:
GPS
Electronic topographic map
GIS Address matching
Other
Unknown

Describe location:
Describe suspected or confirmed release (nature of release, time/date of release, quantity of release, amount of free
Product:
Root cause was a faulty pump fuel line, spill discovered 7:30 AM on 4-6-2023, more than 25
Gallons of diesel fuel was released, cleanup complete on 4-6-2023
Describe initial response/abatement (time/date release stopped, cleanup begun/completed, quantity of product
soil removed, confirmation sampling):
Release was stopped at 7:30 AM, cleanup began immediately after with 3rd party contractor
mobilizing to the site at 11 AM, all cleanup was completed by 4 PM on 4-6-2023.
Approximately 4500 gallons of water and 5 CY of contaminated soil removed from site.
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 Cause of Release Type of Release Product Type Released
(Check one to indicate primary (Check one to indicate primary (Check one) (Check one to indicate primary petroleum product
source) cause) 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 faulty fuel line
Definitions presented on reverse

Petroleum
Both Petroleum
& Non-Petroleum

Location
(Check one)
Facility
Residence
Highway/Road
Railway
Other
Gasoline/ Diesel/ Diesel/Veg. Oil
Kerosene Blend E11 – E20 Vegetable Oil 100% E21 – E84 Heating Oil E85 – E99 Waste Oil Ethanol 100% Mineral Oil-no
PCBs Mineral Oil-PCBs Other Petroleum
Products
Ownership
Municipal Military Unknown Private Federal County State

Operation Type
Public Service Agricultural Residential Education/Relig. Industrial Commercial Mining
Guidance presented on reverse
UST Form 62 (04/10) Page 1 of 2

IMPACT ON DRINKING WATER SUPPLIES

Water Supply Wells Affected? Yes No Unknown Number of Water Supply Wells Affected
List of Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
1.
2.
3.
PARTY RESPONSIBLE FOR RELEASE
(if the source of the release is not an AST system or if it is an AST system and there is a responsible party other than the AST system owner/ operator)
Name of Person/Company: Ames Construction

Address: 2500 County Rd 42 W

City: Burnsville State: MN Zip Code: 55337 Telephone Number 952-435-7106
Email Address: [e-mail] Contact: David Flowers
AST SYSTEM OWNER (if the source of the release is an AST system)
AST Owner/Company: Ames Construction Address: 2500 County Rd 42 W
City: Burnsville State: MN Zip Code: 55337 Telephone Number: 952-435-7106
AST SYSTEM OPERATOR (if the source of the release is an AST system)
UST Operator/Company: Address
City State Zip Code Telephone Number
LANDOWNER AT LOCATION OF INCIDENT
Landowner: Toyota Motor Company Address: 5938 Julian Airport Rd
City: Liberty State: NC Zip Code: 27239 Telephone Number: 859-322-3387
Email Address: [e-mail] Contact: Michael Robinson Title: Senior Manager
Draw Sketch of Area or Provide Map (showing incident site, location of release, two major road intersections, potential
receptors)
Attach sketch or map to form.
Give Directions to Incident Site Attach directions to form if necessary.
Person Reporting Incident: David Flowers Company: Ames Construction Telephone Number: 612-499-2419
Title: Project Manager Address: 5938 Julian Airport Rd, Liberty NC 27239 Date: 4-6-2023
Email Address: [e-mail]
UST Form 62 (04/10) Page 2 of 2
Definitions of Sources
AST (Tank): means the tank is used to store product
AST Piping: means the piping and connectors running from the tank to the dispenser or other end-use equipment
AST Dispenser: includes the dispenser and the equipment used to connect the dispenser to the piping
AST Delivery Problem: identifies releases that occurred during product delivery to the tank.
OTR Vehicle Tank: means the tank is used to store product to fuel an over the road vehicle
OTR Bulk Transport Tank: means a tank that is used to transport product in bulk over the road (by truck)
RR Bulk Transport Tank: means a tank that is used to transport product in bulk by train
Transformer: means electrical transformer
Other: serves as the option to use when the release source is known but does not fit into one of the preceding categories
Unknown: identifies releases for which the source has not been determined
Definitions of Causes
Spill (Accidental): use this cause when a spill occurs accidentally (e.g., when the delivery hose is disconnected from a fill pipe)
Spill (Intentional): use this cause when a spill occurs intentionally (e.g., intentional dumping or breakage)
Corrosion: use when a metal tank, piping, or other component has a release due to corrosion
Physical or Mechanical Damage: use for all types of physical or mechanical damage, except corrosion
Equipment failure: use when a release occurs due to equipment failure other than corrosion or physical or mechanical damage
AST 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)
AST Installation Problem: use when the problem is determined to have occurred specifically because the AST system was not installed properly Other:
use this option when the cause is known but does not fit into one of the preceding categories
Unknown: use when the cause has not been determined
Guidance: Ownership and Operator Type
Ownership select the category which describes owner of the AST system, bulk transport tank, or other release source
Operator Type select the category which describes the operation in which owner uses the AST system, bulk transport tank, or other release source