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Home My WebLink AboutWS-10207_45352_CA_UST-61_20200326 UST-61 24-Hour Release and UST Leak Reporting Form. For Releases 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 in NC 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) N Confirmed Soil Contamination ?(Y/N) Y Samples Taken?(Y/N) Y Free Product? (Y/N) N If Yes, State Greatest Thickness NA Facility ID Number 0-0-23990 Date Leak Discovered 3-25-2020 Comm/Non-Commercial? Comm Reg/Non-regulated? INCIDENT DESCRIPTION Incident Name: Creston Superette Address: 12295 Hwy 88 West County: Ashe City/Town: Creston Zip Code: 28640 Regional Office (circle one): Asheville, Mooresville, Fayetteville, Raleigh, Washington, Wilmington, Winston-Salem Latitude (decimal degrees): 36.44771 Longitude (decimal degrees) : -81.60666 Obtained by: ・GPS ・Topographic map ・GIS Address matching X Other ・Unknown Describe location: UST 10B Form 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) During removal of three fuel dispensers and the piping associated with the three USTs that were closed by removal, soil beneath the dispensers and piping exhibited high TPH‐GRO & TPH‐DRO concentrations. Over‐excavation of these soil was conducted until confirmation samples were collected. Petroleum contamination was also identified in soils that were above the three USTs. Contaminated soils were transported off‐site to a permitted disposal facility. HOW RELEASE WAS DISCOVERED (Release Code) (Check one) ・Release Detection Equipment or Methods X 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 Cause of Release Type of Release Product Type Released (Check primary source) (Check primary cause) (Check one) (Check primary product type released) ・ Tank ・ Piping X Dispenser ・ Submersible Turbine Pump ・ Delivery Problem ・ Spill Bucket ・Other ・ Unknown Definitions presented on reverse ・ Spill ・ Overfill ・ Corrosion ・ Physical/Mechanical Damage ・ Install Problem ・ Other X Unknown Definitions presented on reverse X Petroleum ・ Non-Petroleum ・ Both Location (Check one) X Facility ・Residence ・Other X Gasoline/ Diesel/ ・ Diesel/Veg. Oil Kerosene Blend ・ Heating Oil ・ Vegetable Oil 100% ・ Other Petroleum ・E10 – E20 Products ・E21 – E84 ・ Metals ・E85 – E99 ・ Other Inorganics ・Ethanol 100% ・ Other Organics ・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 IMPACT ON DRINKING WATER SUPPLIES Water Supply Wells Affected? 1. Yes 2. No 3. Unknown Number of Water Supply Wells Affected Unknown 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 J. Gwyn Gambill, Inc. Point of Contact James G. Gambill Address 681 Beaver Creek School Road City West Jefferson State NC Zip Code 28694-7117 Telephone Number 336-846-5401 UST SYSTEM OPERATOR UST Operator/Company Creston Superette Address 12295 Hwy 88 West City Creston State NC Zip Code 28640 Telephone Number 336-385-3455 LANDOWNER AT LOCATION OF UST INCIDENT Landowner Josephine Owens Address 1230 Little Laurel Road City Creston State NC Zip Code 28615 Telephone Number 336-385-3455 Draw Sketch of Area (showing two major road intersections) or Attach Map See attached Person Reporting Incident: Brian Bellis, P.G. Company: WithersRavenel, Inc. Telephone Number: 919-730-7482 Title: Project Manager Address: 219 Station Road, Unit 101, Wilmington NC 28405 Date: March 26, 2020 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 12295 NC12295 NC12295 NC12295 NC12295 NC12295 NC Highway 88Highway 88Highway 88Highway 88Highway 88Highway 88 WWWWWW Creston Superette 12295 NC Highway 88 W Creston | NC 28615-8608