FA-28889_48905_CA_UST-61_20211014

usT-G{24'Hour Release and usr Leak Reporting Form.
For ReleaSeS This form sh
in NC an underground storage tank (UST) system This form is required to be submitted within 24 hours of discovery of a known or
lncident #
Received
Reported
Region
Suspected Contaminati
Conflrmed GW Contam
Confirmed Soil Contam
Samples Taken?(y/N) y
Free Product? (y/N) _ N lf-- yes, State GreatestThickness
Facitity tD Number 00_0_000001 740-lDate Lea k D iscoverao-T0,,Tzfz02T--
Comm/Non-Comms16;31? -Comln-
Reg/Non-regutated? Reg
-INCIDENT DESCRIPT!O[
Circle K Store #2723019
Address: 400 Drwin Road
City/Town: prn,
Latitude (decimar desrees)r 35.315664 N Longitude (decimar deerees) , ?g.62$41 *-99:Briefly describe
Laboratory analy(ical results ofsoil samples taken during site check activities detected perroleum-relate6 impacts
HOW RELEASE WAS D|SC@
(Check one)
f]Rel""s" Detection Equipment or Methods
! Orring UST Closure/Removat
!eroperty Transfer
!Visual/Odor
lWater in Tank
lWater Supply Well Contamination
l-l Groundwater Contaminalion
!Srrta"" Water Contam ination
ffiOtner (specify) Site Check
Source of Release
(Check ptimary source)
! ranx
! eipins
! Disp"ns",
! Submersible Turbine pump
! o.lir"ry probtem
[] spitt Bucret
!otner
! unknown
SOURCE OF
Cause of Release
(Check pimary cause)
nspirr
! Overnll
! Corrosion
ffi Physicat/Mechanical
Damage
! tnstalt probtem
I otnet
! untno*n
Definitions presented on reverse
I Petroteum
! Non-petroleum
! aotn
Location
(Check one)
IFacitity
!Restdence
!otn"'.
[l Gasolinei Diesel/
Kerosene
! Heating Oit
f] otne, petroleum
Products
! M"t"t.
! Otner tnorganics
! other Organics
! Diesettueg Oil
Blend
! Vegetabte Oit 1000/o
! ero - ezo
l:ezt -ea+! ees - ess
!Ethanot 1oO%
fleor - eos
Ownership
1. Municipal 2
Ooeration TyoeT-FubliCSffie2.AgricUltUral3.Residential4Education/Relig5lndustrial@7Mining
UST Form 61 (02t19)
Page 1 of 2
Z P codt 28334 Raleigh, Washington, Wilmington, Winston-Salem
Obtained by:
!ees
!Topograpnic map
[]Gts Aoor".. matching
!otn",
!unknown
Describe location:
IMPACT ON WATER SUPPLIES
Water Supply Wells Affected? 1. yes
Number of Water Suppty Wells Affected
'. (tnctude users rua#lC. i?Zreii;;i;iii Fio;;; Aiaaiaii<iaiiloinaiilieeilinecessaryJ
1 100 Sirus Court, Suire 100
[phone]
UST SYSTEM OFERATOR
I 100 Situs Court, Suite 100
(9 t9) 774-6700LANDOWNER A
Address
P O. Box 361
Draw Sketch
Site Map Aftached
ATC Associates of NC on b"hulf'o{.C*1. KME 'etephone Number 1e te; SOI_feS:
Dtt" o.tob", toloztorm 61
Definitions of SourcesTank: means the rank that storcs the product and is part o|the underground sr.orage tanr system
:*tt' ,13}3:i"lffiiTd connectors *"'i'g rtu,, ii" tank or sublmersib[il#"; p;p to rhe <rispenser or orher end-use equipmenr (venr. vapor recovery, or lilrt'rtspenser: tncludes the dispenser and the equrpment usetl to connect fte rlispenser to the piping (e g., a rerease from a suction pump or rionr components rocated abovethe shear valve)
:'*"":'"'#::lh:'#Bi[1],fli,?r-" i:,"i['ff,f"'submersible
turbine pump head (rvpicarv rocared in rhc rank sump), the rine leak derector, and t]re piping thalDelivery Problem: identifies releases that'occun"U Ar..fpn Ar.t delivery to the tank. (Typical ated with this souroe are spiils and overlills.):':"' :il;'#;::,",rJ,T;i n""J'* th" ..r;; ,;;;;'"'i, kno*n nuiai,' ".i i* *i ;h. "r ;il;i; s , for rereases from vent ri,.,, ,upo.Utilcrown: identifics releases for *,hich the source has not bcen determiued
Delioitions of CeusesSpill: use this cause whenoverfill: *";;;;;;;;ll eoted from the tank fill pipe or when the nozzle is renroved from the drspenser)
Physicat or M..h";;i ;;; the tank or when the nozzle fails to shut oft'at thc dispensol "'" ' - *'*
except corrosion (e g , puncture oftank or prping, loosc fittings, brokenCorrosio ot
3iJ:X"' is the lbrm ol'rusr)
unrcrown: use when tre cause rras not b [l ,HtHt#:rr:llto monitoring weus)