AS-88540_96759_CA_UST-62_20220718

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
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:
T GPS
T Electronic topographic map
T GIS Address matching
T Other
T Unknown
Describe impacted receptors: Describe location:
HOW RELEASE WAS DISCOVERED (Release Code)
(Check one)
T Observation of Release at Occurrence
T Visual or Olfactory Evidence
T Soil Contamination
T Groundwater Contamination
T Water Supply Well Contamination
T Surface Water Contamination
T Other (specify) _______________
SOURCE OF CONTAMINATION
Source of Release 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)
Definitions presented on reverse
T Spill (Accidental)
T Spill (Intentional)
T Corrosion
T Physical or Mechanical
Damage
T Equipment Failure
T AST Overfill
T AST Installation Problem
T Unknown
T Other ______________
Definitions presented on reverse
T Petroleum
T Both Petroleum
& Non-Petroleum
Location
(Check one)
T Facility
T Residence
T Highway/Road
T Railway
T Other
T Gasoline/ Diesel/
Kerosene
T E11 – E20
T E21 – E84
T E85 – E99
T Ethanol 100%
T Diesel/Veg. Oil
Blend
T Vegetable Oil 100%
T Heating Oil
T Waste Oil
T Mineral Oil-no
PCBs
T Mineral Oil-PCBs
T 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
Y
N
YN NA
Release discovered
(time/date):__6-9-2022__________ _______________________
LOWERY WORLEY PROPERTY
800 N. MAIN STREET MADISON
MARS HILL 28754
35.835998 82.542344
Describe suspected or confirmed release (nature of release, time/date of release, quantity of release, amount of free
product): MOUNTAIN ENVIRONMENTAL CONDUCTED PHASE II SOIL SAMPLING PRIOR TO SALE OF THE PROPERTY. SOIL SAMPLE S-3 CONTAINED TPH-DRO AT A
CONCENTRATION OF 1,600 MG/KG. SOIL REMOVAL ACTIVITIES EXCAVATED 6-TONS OF IMPACTED SOIL. CONFIRMATION SOIL SAMPLES INDICATED NO RISK-BASED
ANALYTES ABOVE APPLICABLE STANDARDS.
Describe initial response/abatement (time/date release stopped, cleanup begun/completed, quantity of product
soil removed, confirmation sampling): IMPACTED SOIL WAS EXCAVATED ON JULY 5, 2022.
NONE
X
X
(Check one to indicate primary
source)
T AST (tank)
T AST Piping/ Dispenser
T AST Delivery Problem
T OTR Vehicle Tank
T OTR Bulk Transport Tank
T RR Bulk Transport Tank
T Transformer
T Unknown
TX Other _______________
X
X
X
X
X PRIOR TO SALE OF PROPERTY
X
X
X
IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected? 1.Yes 2. No 3. Unknown Number of Water Supply Wells Affected ______
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 Address
City State Zip Code Telephone Number
AST SYSTEM OWNER (if the source of the release is an AST system)
AST Owner/Company Address
City State Zip Code Telephone Number
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 Address
City State Zip Code Telephone Number
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 Company Telephone Number
Title Address Date
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
List of Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
1.
2.
3.
LOWERY WORLEY
SAME
SEE ATTACHED MAP
SEE ATTACHED MAP
BRIAN BAUER MOUNTAIN ENVIRONMENTAL SERVICES, INC.828-648-5556
PROJECT MANAGER 1560 PISGAH DRIVE CANTON, NC 28716 7-18-2022
SAME
SAME
4908 LITTLE PINE ROAD
MARSHALL NC 28753
DATA SOURCE: MADISON COUNTY GIS 2019 AERIAL IMAGERY1000NFigure 1 SITE MAPWORLEY PROPERTY800 N. MAIN STREET MARS HILL, NC