AS-29957_49043_CA_UST-61_20230606

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
(DWM USE ONLY) Incident # ________ Risk (H,I,L,U)_______ Received On ________ Received By ________
Reported by (circle one): Phone, Fax or Report Region _______
Incident Name:
Address: County:
City/Town: Zip Code: (circle oneRaleigh, 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)  GPS
 Topographic map
 GIS Address matching
 Other
 Unknown
Describe location:
HOW RELEASE WAS DISCOVERED (Release Code)
(Check one)
 Release Detection Equipment or Methods
 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 (Check primary source) Cause of Release (Check primary cause) Type of Release (Check one) Product Type Released (Check primary product type released)
 Tank
Piping
Dispenser
 Submersible Turbine Pump
 Delivery Problem
 Spill Bucket
 Other
 Unknown
Definitions presented on reverse
 Spill
 Overfill
 Corrosion
 Physical/Mechanical
Damage
 Install Problem
 Other
 Unknown
Definitions presented on reverse
 Petroleum
 Non-Petroleum
 Both
Location
(Check one)
 Facility
 Residence
 Other
 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
Page 1 of 2
Residential Heating Oil UST - Cleveland County PIN 2536893075
409 Whisnant Street Cleveland
Shelby 28150
35.286654 -81.552426
Google Maps
X
Soil sampling was conducted surrounding a residential heating UST, as required by a bank lender and as part of a property
transaction. TPH-DRO concentrations for one of the samples were found to exceed the action levels and indicates that
X X
X
X
X
Suspected Contamination? (Y/N) Yes Confirmed GW Contamination? (Y/N) No Confirmed Soil Contamination ?(Y/N) Yes Samples Taken?(Y/N) Yes Free Product? (Y/N) No If Yes, State Greatest Thickness N/A
Facility ID Number _N/A_________ Date Leak Discovered 6/1/2023 Comm/Non-Commercial? Non-com Reg/Non-regulated? Non-regulated
X X
X
X X
X
X
X
a release has occurred from the UST. No additional assessment has been completed at this time.
IMPACT ON DRINKING WATER SUPPLIES
3. Unknown
Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary
1. 2.
UST SYSTEM OWNER UST Owner/Company
Point of Contact
City State Zip Code Telephone Number
UST Operator/Company
City State Zip Code Telephone Number
Landowner
City State Zip Code Telephone Number
Person Reporting Incident Company Telephone Number
Title Address Date
UST Form 61 (02/19)
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
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
John Hamrick
Address
1311 Mt. Pleasant Church Road
Mooresboro NC 28114
Nathan Simmons Catawba Valley Engineering & Testing 828-578-1431
Geologist P.O. Box 747, Hickory, NC 28603 6/5/2023
FIGURE ATTACHED
Water Supply Wells Affected? 1. Yes 2. No
Number of Water Supply Wells Affect NAed _________________
John Hamrick
John Hamrick
Address
1311 Mt. Pleasant Church Road
Mooresboro 28114NC [phone]
John Hamrick
Address
1311 Mt. Pleasant Church Road
Mooresboro NC 28114
[phone]
[phone]
NSS 23-354
June 2, 2023 Figure 1
P.O.B. 747 NORTH CAROLINAHICKORY
TELE: 828-578-9972 FAX: [phone]
CATAWBA VALLEY
ENGINEERING & TESTING
Site Location Map
409 Whisnant Street
Shelby, North Carolina
DWELLING
Stream