MO-29861_0_CA_UST-61_20230127_UST 61

UST-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) __N____ Samples Taken?(Y/N) __Y____ Free Product? (Y/N) _N____ If Yes, State Greatest Thickness ___N/A___________
Facility ID Number ______________ Date Leak Discovered 1/27/2023__ Comm/Non-Commercial? _Com___ Reg/Non-regulated? ____Non___
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
3023 Wilkesboro Highway
3023 Wilkesboro Highway Iredell
Statesville 28625
35.87-226 -80.940632
During completion of a Phase II ESA as part of a property transaction, petroleum contaminated groundwater was
identified on a vacant residential property located down-gradient of "Yogi Foods" convenience store and gas station.
MTBE was detected at a concentration of 159 ug/L in a temporary groundwater monitoring well, as described in the
attached Phase II ESA Report.
Google Maps
X
X
X X
X
X
X
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
See Attached Sketch
Nathan Simmons Catawba Valley Engineering & Testing 828-578-1431
Geologist PO Box 747, Hickory, NC 3/3/2023
Adjacent Filling Station
Adjacent Filling Station
Adjacent Filling Station
NSS
Figure 1
P.O.B. 747 NORTH CAROLINAHICKORY
FAX: [phone]TELE: 828-578-9972
CATAWBA VALLEY
ENGINEERING & TESTING
Site Location Map
Subject Pro
p
e
r
t
y
115 Country Store/Yogi Foods
3023 and 3027 Wilkesboro Highway
Statesville, North Carolina
22-431
January 25, 2022