MO-30291_0_CA_UST-17A_20231213_Murphy USA 6676

UST-17A UST Suspected Release 24 Hour Notice
Do not use this form to report a 24 hour notice of a Pollution Incident. You must use form UST-61, 24 Hour Release and UST Leak Reporting Form.
This form must be used to report to DEQ, within 24 hours of discovery, a Suspected Release from any of the following:
a)Failed or inconclusive leak detection or tightness test results. This includes positive test results, such as “Increase”, whichindicates the level in the UST system has increased more than 0.2 gph.
b)Unusual operating conditions which can include, but are not limited to: the erratic behavior of dispensing equipment; theunexplained presence of water in the tank; the presence of fuel in containment sumps or interstitial spaces; or the degradation ofany equipment or element of an underground storage tank system to the point where that equipment or element can not reasonablybe expected to perform its intended function.
c)Internal inspection results such as, perforations, corrosion holes, weld failures, or other similar defects that indicate a releasecould have occurred.
If you have more than four UST systems to report suspected releases, then attach additional sheets of the UST-17A form. You onlyneed to list the UST systems at your site that have suspected releases.
Within 7 days of discovery, submit a UST-17B form to document the response activities taken to investigate the suspected release.
Please submit this form to: NCDEQ/DWM, UST Section1646 Mail Service Center Raleigh, North Carolina 27699-1646
OR
Fax to [phone] OR [e-mail]
I. UST OWNER II. UST FACILITY
Name: Murphy USA
Name: Murphy Express #6676
Facility ID: 00-0-0000036309
Address: 200 E. Peach Street
Address: 557 A 3rd Street SW
City: El Dorado
State: AR
Zip: 71731
City: Taylorsville
County: Alexander
Person Reporting: Stephen Powlus
Title of Person Reporting: Senior Environmental Specialist Telephone Number: [phone]
Date Submitted: 9/28/2023
III. UST INFORMATION
Tank Number / Size: / / / /
Product Stored: Gasoline
Location and/or source of suspected release: (check all that apply)
Tank
Piping
Tank Sump
Dispenser Sump
Spill Bucket
Internal Inspection
Other (Explain in comments)
Tank
Piping
Tank Sump
Dispenser Sump
Spill Bucket
Internal Inspection
Other (Explain in comments)
Tank
Piping
Tank Sump
Dispenser Sump
Spill Bucket
Internal Inspection
Other (Explain in comments)
Tank
Piping
Tank Sump
Dispenser Sump
Spill Bucket
Internal Inspection
Other (Explain in comments)
Leak detection method or other observation that indicates a suspected release. (e.g., ATG, SIR, visual contamination, fuel in sump, etc.):
Spill bucket test gauge
found in "Test" mode.
Failed/Inconclusive date or date that leak detection method suspected release discovered:
IV.COMMENTS
Premium Double-Walled Spill bucket test gauge was in “Test” mode (showing red). MUSA has contacted a company about making
repairs to the spill bucket.
UST-17A Revised 10/2018 http://www.wastenotnc.org/
09/26/2023