WA-27924_38759_CA_UST-61_20190429

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) ________
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)T GPS
T Topographic map
T GIS Address matching
T Other
T Unknown
Describe location:
HOW RELEASE WAS DISCOVERED (Release Code)
(Check one)
T Release Detection Equipment or Methods
T During UST Closure/Removal
T Property Transfer
T Visual/Odor
T Water in Tank
T Water Supply Well Contamination
T Groundwater Contamination
T Surface Water Contamination
T Other (specify) _______________
SOURCE OF CONTAMINATION
Source of Release
(Check one to indicate primary
source)
Cause of Release
(Check one to indicate primary
cause)
Type of Release
(Check one)
Product Type Released
(Check one to indicate primary product type
released)
T Tank
T Piping
T Dispenser
T Submersible Turbine Pump
T Delivery Problem
T Other
T Unknown
Definitions presented on reverse
T Spill
T Overfill
T Corrosion
T Physical or Mechanical
Damage
T Install Problem
T Other
T Unknown
Definitions presented on reverse
T Petroleum
T Non-Petroleum
T Both
Location
(Check one)
T Facility
T Residence
T Other
T Gasoline/ Diesel/
Kerosene
T Heating Oil
T Other Petroleum
Products
T Metals
T Other Inorganics
T Other Organics
T Diesel/Veg. Oil
Blend
T Vegetable Oil 100%
T E10 – E20
T E21 – E84
T E85 – E99
T Ethanol 100%
T 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 (02/08)Page 1 of 2
Y Y
Y Y NNA
NA
4/11/2019Comm
Regulated
28504 _____________
35.269655
X
Former Dr. Pepper Distribution Facility
The 8,000-gallon diesel UST system was closed by removal on April 11, 2019. PID measurements indicate VOCs are present in the soils excavated to remove the
UST system at concentrations ranging from 0.1 to 79.3 ppm. Closure soil samples SW-1 through SW-8 were collected from the excavation sidewalls (since
ground-water was observed in the excavation) at a depth of about 3 feet BGS for laboratory analysis of GRO and DRO using EPA Method 8015C. The soil
analytical data indicate DRO is present in samples SW-1 through SW-8 at concentrations ranging from 15.6 to 23.9 mg/kg, which is below the TPH cleanup level.
in addition, the soil analytical data indicate GRO is not present in samples SW-1 through SW-8 at concentrations exceeding the analytical method detection limits.
Since the bottom of the UST is below the water table, Type II monitoring well MW-1 was installed on April 12, 2019 at a location near center of the UST system.
semi-volatiles using EPA Method 625 BNA with TICs, and aromatic/aliphatic range hydrocarbons using MADEP EPH and VPH. The
The ground-water analytical data indicate naphthalene is present in monitoring well MW-1 at a concentration slightly exceeding 15A NCAC 2L ground-water
standards. The ground-water analytical data also indicate total C9-C18 aliphatics, o,m,p-xylenes, n-propylbenzene, n-butylbenzene, isopropylbenzene, and
acetone are present in monitoring well MW-1 at concentration decisively below 15A NCAC ground-water standards. In addition, the target list of analytes for
EPA Method 625 BNA is not present in monitoring well MW-1 at concentrations exceeding the analytical method detection limits.
Kinston
304 Harding Avenue Lenoir
77.585005
Monitoring well MW-1 was sampled on April 12, 2019 for laboratory analsysis of volatiles using EPA Method 6200B (plus MTBE, IPE, EDB),
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 (02/08)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
___
NA
Harvey Enterprises
P.O. Box 189Ruth Heath
Kinston NC 28502 [phone]
Dr. Pepper Distribution Facility Out of Business
Kinston NC 28504 Ou of Business
Harvey Enterprises
Kinston NC 28504 [phone]
See attached map (Lenoir County GIS map)
Thomas J. Benthall, Jr.
Sr. Project Manager 1450 Johnson Drive, Williamston, NC 27892 4/29/2019
[phone] Lighthouse Technical, P.C./ECES, Inc.
P.O. Box 189