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Home My WebLink AboutFA-29634_48761_CA_UST-61_20221027UST-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) ________ Confirmed GW Contamination? (Y/N) ______ Confirmed Soil Contamination ?(Y/N) ______ Samples Taken?(Y/N) ______ Free Product? (Y/N) _____ If Yes, State Greatest Thickness ______________ Facility ID Number ______________ Date Leak Discovered ___________ Comm/Non-Commercial? ________ Reg/Non-regulated? _____________ INCIDENT DESCRIPTION Incident Name: Address: 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: 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  Other (specify) _______________ 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 Triton Quick Check 205 E. Jackson Blvd Erwin Harnett 28339 35.334328 -78.672800 48761 FA-29634 U10/27/22 MHH > KEC FAY EMAILED IMPACT ON DRINKING WATER SUPPLIES Water Supply Wells Affected? 1. Yes 2. No 3. Unknown 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 3502 Hayes Road • Monroe, North Carolina 28110 113 West Firetower Road, Suite G • Winterville, North Carolina 28590 Phone (704) 845-4010 • (888) 870-4133 • Fax (704) 845-4012 Engineering Certification: C-2727 • Geology Certification: C-127 UVF Trilogy Analytical Report Samples Collected: October 26, 2022 Samples Analyzed: October 27, 2022 Site Name: Triton Quick Check Site Address: 205 East Jackson Boulevard, Erwin, NC GRI Project Number: 4853 October 28, 2022 AJ Discepolo, GIT Operator Technical Procedures Sample Collection and Handling Soil samples may be collected using any acceptable procedure. Sampler must use a clean pair of nitrile gloves for each sample collected. The sample will be placed in a clean, sealable bag (ziplock). Once collected, the sample must be analyzed immediately or placed on ice. The sample may be kept on ice for up to 48 hours prior to UVF analyses. If the sample cannot be analyzed within 48 hours, the sample may be extracted and kept at 4 degrees C for up to 14 days. Proper chain-of-custody procedures must be followed. Calibration The UFV Trilogy has standard calibrations stored for the following analysis:  GRO  DRO  Total PAH  Target PAH  Heavy PAH Prior to use, calibration standards are used to perform a 5-point verification on the factory stored calibrations for GRO and DRO. The calibration standards used are as follows: GRO  0.5 ppm  1 ppm  3 ppm  5 ppm  10 ppm DRO  0.1 ppm  0.5 ppm  1 ppm  3 ppm  5 ppm Operation Sample Extraction  5mg of soil are weighed into a clean extraction jar  Methanol is added to the extraction jar to create a 2x or 4x dilution o 2x Dilution: 10 mL of methanol o 4x Dilution: 20 mL of methanol  The extraction jar is shaken for several minutes to thoroughly mix the soil with solvent (methanol)  The mixture is allowed to settle for several minutes  A clean syringe is used to draw liquid from the extraction jar  A clean filter is attached to the end of the syringe and the liquid dispensed through the filter into a clean test tube  This liquid is referred to as the extraction Dilution Preparation  An adjustable micropipette is used to precisely measure out the amount of extract needed for the dilution Technical Procedures  The measured out amount of the extract is added to a clean test tube and methanol is added dilute the extract. Examples of dilutions are shown below: Extract Amount 500 μL 200 μL 100 μL 50 μL 25 μL Add Solvent to the 5 mL line 5 mL line 5 mL line 5 mL line 5 mL line 2x Extract Dilution Factor 20x 50x 100x 200x 400x 4x Extract Dilution Factor 40x 100x 200x 400x 800x Sample Analyzation  The dilution is shaken to thoroughly mix, then poured into a clean glass cuvette  The desired module is inserted into the UVF Trilogy and the corresponding factory calibration is selected  “Measure Fluorescence” is pressed on the touchscreen and the reading is recorded  The reading should be between the concentrations of the calibration standards (GRO: 0.5-10 ppm; DRO 0.1-5 ppm) o Reading below the calibration standard range are recorded as below the detection limit  Detection Limit = (lower range of calibration standards range) x dilution factor (i.e. a GRO sample with a 100x dilution factor has a detection limit of 50 ppm) o Readings above the calibration standard range should be further diluted and reanalyzed o Negative readings are an indication of quenching (see below)  The reading is multiplied by the dilution factor to calculate the final concentration  Check suspected contaminated samples for quenching by running additional dilutions o According to the siteLAB Quick Reference Guide: “Quenching” can occur when the detector is swamped by too many hydrocarbons or organic interferences, producing low or negative concentrations. Test the sample at multiple dilutions to confirm results are linear and accurate.” QA/QC Calibration  The UFV Trilogy will be calibrated daily prior to use  The calibration results will be saved and entered into the calibration log Method Blank  A method blank of methanol will be analyzed following calibration and following the last sample analyzed for each site Duplicates  One duplicate will be analyzed for every 20 samples  The duplicate will be prepared from the extract of the sample and diluted to the same factor as the sample analyzed Project Name:Date Collected: Project Number:Date Analysed: Project Manager:Operator: Sample ID Matrix Dilution Factor x GRO Output (ppm) =GRO Value (mg/Kg) Dilution Factor x DRO Output (ppm) =DRO Value (mg/Kg) SS-1 Soil 40 0.64 25.6 NR NR NR SS-2 Soil 800 9.14 7,312 NR NR NR UVF Analytical Report siteLAB UVF Trilogy 10/27/2022 10/26/2022 AJ Discepolo Triton Quick Check 4853 Eric Eubanks Triton Quick Check Report Date: 10/28/2022 Page: 1 of 1 Calibration Standard Output Calibration Standard Output 0.5 0.5 0.1 0.14 1 0.92 0.5 0.55 3 2.75 1 1.1 5 4.41 3 3.16 10 8.85 5 5.45 0 0.18 0 0 0 0.14 0 0.01 Field Calibration GRO DRO Method Blank 10/27/2022 SAMPLE ID TIME DILUTION GRO VALUE SS-1 1427 40 3.27 130.8 SS-2 1429 40 52.62 2104.8 SS-2 1430 100 39.65 3965 SS-2 1432 200 29.27 5854 SS-2 1434 400 16.74 6696 SS-2 1436 800 9.14 7312 SS-2 DUP.1439 800 8.99 7192