HomeMy WebLinkAboutFA-96083_97180_CA_UST-62_20231122UST-62 24-Hour Notification of Discharge Form
For Non-UST
Releases of
Petroleum in NC
This form should be completed and submitted to the UST Section’s regional office following a known or suspected release of petroleum from a source other than an underground storage tank. This form is required to be submitted within 24 hours of discovery of a known or suspected petroleum release
(DWM USE ONLY)Incident # ___________ Priority Rank (H,I,L,U) _____Received (time/date) ___________________________Received by ________________ Region __________Reported by (circle one): Phone, Fax or Report
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(free product), state greatest thickness: _____feet
Release discovered(time/date):_~18:30_______ _11/9/2023______________
INCIDENT DESCRIPTION
Incident Name: APC Hwy 95 Tanker Spill
Address (street number/name): NCDOT right of Way North of I-95 S exit 33 County: Robeson
City/Town: St. Pauls Zip Code: 28371 Regional Office (circle one): Asheville, Mooresville, Fayetteville, Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): 34.85750417357012 Longitude (decimal degrees):-78.96609540464634 Obtained by:
Describe suspected or confirmed release (nature of release, time/date of release, quantity of release, amount of free product):
Associated Petroleum Carrier's (APC) tractor trailer (gasoline tanker) accident (no APC fault) on 11/8/203 at ~ 18:30
resulted in tractor trailer roll-over and gasoline tanker leak. Approximately 1,200-gallons of gasoline released
Describe initial response/abatement (time/date release stopped, cleanup begun/completed, quantity of product soil removed, confirmation sampling):
GPS
Electronic topographic map
GIS Address matching
Other
Unknown
Describe impacted receptors:Describe location:
HOW RELEASE WAS DISCOVERED (Release Code)(Check one)
Observation of Release at Occurrence
Visual or Olfactory Evidence
Soil Contamination
Groundwater Contamination
Water Supply Well Contamination
Surface Water Contamination
Other (specify) _______________
SOURCE OF CONTAMINATION
Source of Release
(Check one to indicate primary source)
Cause of Release
(Check one to indicate primarycause)
Type of Release
(Check one)
Product Type Released
(Check one to indicate primary petroleum product type released)
AST (tank)
AST Piping/ Dispenser
AST Delivery Problem
OTR Vehicle Tank
OTR Bulk Transport Tank
RR Bulk Transport Tank
Transformer
Unknown
Other ______________
Definitions presented on reverse
Spill (Accidental)
Spill (Intentional)
Corrosion
Physical or Mechanical
Damage
Equipment Failure AST
Overfill
AST Installation Problem
Unknown
Other ______________
Definitions presented on reverse
Petroleum
Both Petroleum
& Non-Petroleum
Location
(Check one)
Facility
Residence
Highway/Road
Railway
Other
Gasoline/ Diesel/
Kerosene
E11 –E20
E21 –E84
E85 –E99
Ethanol 100%
Diesel/Veg. Oil
Blend
Vegetable Oil 100%
Heating Oil Waste
Oil
Mineral Oil-no
PCBs
Mineral Oil-PCBs
Other Petroleum
Products ________
Ownership1.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. MiningGuidance presented on reverse
UST Form 62 (04/10)Page1of2
X : Google
West side of I-95 S, north of Exit 33, ~375'
south of bridge over Little Marsh Swamp Creek
Initial emergency response conducted by local responders, APC contractor placed sorbent boom in the adjacent wetland(after initial responders allowed access) early on 11/10/203
Unknown, possible runoff to Little Marsh Swamp Creek
X
X
X X X
X
X
FA-96083
97180 I
11/10/2023 FAY
Phone
IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected?1. Yes 2. No 3. Unknown Number of Water Supply Wells Affected ______
List of Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
1.
2.
3.
PARTY RESPONSIBLE FOR RELEASE
(if the source of the release is not an AST system or if it is an AST system and there is a responsible party other than the AST system owner/ operator)
Name of Person/Company
Address
City State Zip Code Telephone Number
AST SYSTEM OWNER (if the source of the release is an AST system)AST Owner/Company
Address
City State Zip Code Telephone Number
AST SYSTEM OPERATOR (if the source of the release is an AST system)AST Operator/Company
Address
City State Zip Code Telephone Number
LANDOWNER AT LOCATION OF INCIDENTLandowner Name
Address
City State Zip Code Telephone Number
Provide Map Or Drawing (showing incident site, location of release, two major road intersections, and potential receptors)
Give Directions to Incident Site Attach directions to form if necessary.
Person Reporting Incident Company Telephone Number
Title Address Date
UST Form 62 (04/10)Page2of2
Definitions of Sources
AST (Tank): means the tank is used to store product
AST Piping: means the piping and connectors running from the tank to the dispenser or other end-use equipment
AST Dispenser:includes the dispenser and the equipment used to connect the dispenser to the piping
AST Delivery Problem: identifies releases that occurred during product delivery to the tank.
OTR Vehicle Tank: means the tank is used to store product to fuel an over the road vehicle
OTR Bulk Transport Tank: means a tank that is used to transport product in bulk over the road (by truck)
RR :bulk Transport Tank: means a tank that is used to transport product in bulk by train
Transformer: means electrical transformer
Other: serves as the option to use when the release source is known but does not fit into one of the preceding categories
Unknown: identifies releases for which the source has not been determined
Definitions of CausesSpill (Accidental): use this cause when a spill occurs accidentally(e.g.,when the delivery hose is disconnected from a fill pipe)
Spill (Intentional): use this cause when a spill occurs intentionally (e.g., intentional dumping or breakage)
Corrosion: use when a metal tank, piping, or other component has a release due to corrosion
Physical or Mechanical Damage: use for all types of physical or mechanical damage, except corrosion
Equipment failure: use when a release occurs due to equipment failure other than corrosion or physical or mechanical damage
AST 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)
AST Installation Problem: use when the problem is determined to have occurred specifically because the AST system was not installed properly
Other: use this option when the cause is known but does not fit into one of the preceding categories
Unknown: use when the cause has not been determined
Guidance: Ownership and Operator TypeOwnership select the category which describes owner of the AST system, bulk transport tank, or other release source
Operator Type select the category which describes the operation in which owner uses the AST system, bulk transport tank, or other release source
Email
Email
Email
Email
Vehicle driver fleeing State Highway Patrol pursuit - Associated Petroleum Carriers, Inc. - Jared Bishop
jbishop@apccorporate.com 1746 Union Street
Spartanburg SC 29302 864-237-3483
NCODT Right of Way - John Nunn
jmnunn@ncdot.gov PO Box 1150
Fayetteville NC 28302 910-364-6000
Ben Ashba, PG Geosyntec 910-400-1010
Project Manager 314 Walnut St. Suite 200, Wilmington, NC 28401 11/23/2023
FA-96083_97180
APC I-95 S. Gasoline Tanker Spill – 11/9/2023