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Home My WebLink AboutFA-30270_49303_CA_UST-62_20231204UST-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) _Y___ Samples Taken?(Y/N) __Y___ Free Product? (Y/N) ___N__ If Yes, State Greatest Thickness ______________ Facility ID Number _None Date Leak Discovered _12-21-2021 _ Comm/Non -Commercial? Non-Com Reg/Non-regulated? _ Non-Reg_ INCIDENT DESCRIPTION Incident Name: Wood Property Address: 1633 Cornwallis Road County: Johnston City/Town: Garner Zip Code: 27529 Regional Office (circle one): Asheville, Mooresville, Fayetteville, Raleigh, Washington, Wilmington, Winston-Salem Latitude (decimal degrees): N 35.5723 Longitude (decimal degrees) : W 78.5580 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 X GIS Address matching  Other  Unknown Describe location: HOW RELEASE WAS DISCOVERED (Release Code) (Check one) Release Detection Equipment or Methods During UST Closure/Removal x Phase II ESA for Property Transfer Visual/Odor  Water in Tank  Water Supply Well Contamination SX oil 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) X Tank  Piping Dispenser  Submersible Turbine Pump  Delivery Problem  Spill Bucket  Other Unknown Definitions presented on reverse  Spill Overfill Corrosion  Physical/Mechanical Damage  Install Problem X Other Unknown Definitions presented on reverse PetroleumX  Non-petroleum  Both Location (Check one) Facility RXesidence Other X 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 il An Initial Abatement Action Report will be prepared for the release because the owner wishes to obtain a letter of no further action from the NC-DEQ. One soil sample collected from adjacent to a 550-gallon farm diesel fuel UST by others during December 21, 2021 was found to contain GRO at 14,100 mg/kg and DRO at 609 mg/kg. The tank was subsequently by others during 2023 . Petroleum contaminated soils were subsequently removed during November 28, 2023 . FA-30270 49303 U11/30/23 KEC FAY PHONE 11/30/23 EMAIL 12/4/23 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:Wood Property Point of Contact: Phillip Wood Address: 1633 Cornwallis Road City: Garner State: NC Zip Code: 27529 Telephone Number: (919) 337- 3174 UST SYSTEM OPERATOR UST Operator/Company: Phillip Wood Address: 1633 Cornwallis Road City: Garner State: NC Zip Code: 27529 Telephone Number: (919) 337- 3174 LANDOWNER AT LOCATION OF UST INCIDENT Landowner: Phillip Wood Address: 1633 Cornwallis Road City: Garner State: NC Zip Code: 7529 Telephone Number Draw Sketch of Area (showing two major road intersections) or Attach Map Person Reporting Incident Tom Will Company East Coast Environmental, PA Telephone Number 919-772-0268 Title Geologist Address 3815 Junction Boulevard, Raleigh, NC 27603 Date 12-4-23 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 (919) 337-3174 East Coast Environmental, P.A. 3815 Junction Boulevard Raleigh, North Carolina 27603 (919) 349-5969 Figure 1 Site Map With Former UST and AST Locations Wood Property 1633 Cornwallis Road Garner, Johnston County, NC Scale:Prep. By:Rev. By:Date: 1” = 20'TRW TRW 12/6/2023 N Cornwallis Road Former AST Area And Excavation. - Soil Sample Locations Former UST Area and Excavation.