AS-29878_48972_CA_UST-61_20220418

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
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
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
Title Address Date
Person Reporting Incident Company Telephone Number
Topo North America™ 10
Location: 35.820122 °N / 81.679510 °W
FIGURE 1. SITE LOCATION
Data use subject to license.
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TN
MN (7.7°W)
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ftm
Scale 1 : 12,000
1" = 1,000.0 ft Data Zoom 14-3