WA-30685_49638_CA_UST-61_20240719

UST-61 24-Hour Release and UST Leak Reporting Form.
For Releases This form should be completed and submitted to the UST Section's regional office following a known or suspected release from
in NC 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) Suspected Contamination? (Y/N) Facility ID Number Incident# Risk (H,l,L,U) Confirmed GW Contamination? (Y/N) ___ Date Leak Discovered Received On Received By Confirmed Soil Contamination ?(Y/N) ___ Comm/Non-Commercial? Reported by (circle one): Phone, Fax or Report Samples Taken?(Y/N) __ Reg/Non-regulated? Region Free Product? (Y/N) __ If Yes, State Greatest Thickness
INCIDENT DESCRIPTION Incident Name:
Address: I County:
City/Town: Zip Code: I 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 OGPS of release, amount of free oroduct oresent and recoverv efforts, initial resoonses conducted, imoacts to receotors)□Topographic map
OGls Address matching
O0ther □unknown
Describe location:
HOW RELEASE WAS DISCOVERED (Release Code)
(Check one) □Release Detection Equipment or Methods Dvisual/Odor □Groundwater Contamination
ODuring UST Closure/Removal Dwater in Tank Dsurtace Water Contamination □Property Transfer Dwater Supply Well Contamination O0ther (specify)
SOURCE OF CONTAMINATION
Source of Release Cause of Release T�ee of Release Product T�ee Released
(Check primary source) (Check primary cause) (Check one) (Check primary product type released)
OTank □spill D Petroleum D Gasoline/ Diesel/ 0 DieselNeg. Oil □Piping □overfill D Non-Petroleum Kerosene Blend
D Dispenser D Corrosion OBoth D Heating Oil 0 Vegetable Oil 100%
D Submersible Turbine Pump D Physical/Mechanical D Other Petroleum OE10-E20
Location Products OE21-E84 D Delivery Problem Damage (Check one) D Metals D Install Problem OE85-E99 □spill Bucket D Other □Facility D Other lnorganics D Ethanol 100% Oother D Unknown □Residence D Other Organics OE01-E09 D Unknown O0ther
Definitions presented on reverse Definitions presented on reverse
Ownershie 1.Municipal 2. Military 3. Unknown 4. Private 5. Federal 6. County 7. State
Oeeration Tl£ee 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
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
Address
City I State Zip Code I Telephone Number
UST SYSTEM OPERATOR UST Operator/Company
Address
City I State Zip Code I Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT Landowner
Address
City I State Zip Code I Telephone Number
Draw Sketch of Area (showing two major road intersections) or Attach Map
Person Reporting Incident Company Telephone Number
Title Address Date
UST Form 61 (02/19) Page2 of2
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 Point of Contact
Email
Email
Email
138 Rowe Street
Goldsboro
Yosefh Assaedi
[e-mail]
Monitoring Well
Soil Boring
Legend
(6746) Joe's Store & Grill 7/19/2024Date
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Summary of Hits Page 1 of 2
Job Number:FC16419
Account:GRI (Geological Resources Inc.)
Project:Joe's Store & Grill; 909 Hwy 117 S, Goldsboro, NC
Collected:06/12/24
Lab Sample ID Client Sample ID Result/
Analyte Qual RL MDL Units Method
FC16419-1 TRIP BLANK
No hits reported in this sample.
FC16419-2 MW-1
Benzene 193 5.0 1.3 ug/l SM 6200B
Ethylbenzene 2000 13 3.1 ug/l SM 6200B
Naphthalene 498 5.0 1.3 ug/l SM 6200B
Toluene 143 5.0 1.3 ug/l SM 6200B
Xylene (total)150 15 2.5 ug/l SM 6200B
2,4-Dimethylphenol 12.2 5.3 0.79 ug/l EPA 625.1
1-Methylnaphthalene 31.3 5.3 0.56 ug/l EPA 625.1
2-Methylnaphthalene 62.5 5.3 0.64 ug/l EPA 625.1
Naphthalene 235 21 2.1 ug/l EPA 625.1
Total TIC, Semi-Volatile 5396 J ug/l
Benzene 213 1.0 1.0 ug/l MADEP VPH REV 2.1
Ethylbenzene 2890 20 10 ug/l MADEP VPH REV 2.1
Methyl Tert Butyl Ether 22.2 2.0 1.0 ug/l MADEP VPH REV 2.1
Naphthalene 300 5.0 3.0 ug/l MADEP VPH REV 2.1
Toluene 136 2.0 1.0 ug/l MADEP VPH REV 2.1
m,p-Xylene 4840 40 20 ug/l MADEP VPH REV 2.1
o-Xylene 148 2.0 1.0 ug/l MADEP VPH REV 2.1
C5- C8 Aliphatics (Unadj.)4950 1000 350 ug/l MADEP VPH REV 2.1
C9- C12 Aliphatics (Unadj.)18100 5000 1800 ug/l MADEP VPH REV 2.1
C9- C10 Aromatics (Unadj.)9020 5000 1800 ug/l MADEP VPH REV 2.1
C5- C8 Aliphatics 4600 1000 350 ug/l MADEP VPH REV 2.1
C9- C12 Aliphatics 1200 1000 350 ug/l MADEP VPH REV 2.1
C9- C10 Aromatics 9020 5000 1800 ug/l MADEP VPH REV 2.1
2-Methylnaphthalene 52.6 4.1 2.0 ug/l MADEP EPH REV 2.1
Naphthalene 187 B 4.1 2.0 ug/l MADEP EPH REV 2.1
C11-C22 Aromatics (Unadj.)787 B 200 82 ug/l MADEP EPH REV 2.1
C11-C22 Aromatics 547 B 200 82 ug/l MADEP EPH REV 2.1
C9-C18 Aliphatics 435 B 200 51 ug/l MADEP EPH REV 2.1
C19-C36 Aliphatics 74.8 JB 200 51 ug/l MADEP EPH REV 2.1
FC16419-3 SB-2 (5)
Benzene 0.0014 J 0.0051 0.0013 mg/kg SW846 8260D
2-Butanone (MEK)0.0245 J 0.026 0.0075 mg/kg SW846 8260D
n-Butylbenzene 0.0010 J 0.0051 0.0010 mg/kg SW846 8260D
Carbon Disulfide 0.0044 J 0.0051 0.0010 mg/kg SW846 8260D
Isopropylbenzene 0.0011 J 0.0051 0.0010 mg/kg SW846 8260D
Methylcyclohexane 0.0530 0.0048 0.0016 mg/kg SW846 8260D
n-Propylbenzene 0.0037 J 0.0051 0.0010 mg/kg SW846 8260D
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FC16419
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Summary of Hits Page 2 of 2
Job Number:FC16419
Account:GRI (Geological Resources Inc.)
Project:Joe's Store & Grill; 909 Hwy 117 S, Goldsboro, NC
Collected:06/12/24
Lab Sample ID Client Sample ID Result/
Analyte Qual RL MDL Units Method
Di-n-butyl Phthalate 0.377 0.36 0.072 mg/kg SW846 8270E
Fluoranthene 0.0414 J 0.18 0.018 mg/kg SW846 8270E
1-Methylnaphthalene 0.0208 J 0.18 0.018 mg/kg SW846 8270E
2-Methylnaphthalene 0.0345 J 0.18 0.018 mg/kg SW846 8270E
Phenanthrene 0.0386 J 0.18 0.018 mg/kg SW846 8270E
Pyrene 0.0299 J 0.18 0.021 mg/kg SW846 8270E
o-Xylene 0.104 J 0.11 0.054 mg/kg MADEP VPH REV 2.1
C5- C8 Aliphatics (Unadj.)3.28 J 5.4 1.9 mg/kg MADEP VPH REV 2.1
C9- C12 Aliphatics (Unadj.)7.97 5.4 1.9 mg/kg MADEP VPH REV 2.1
C9- C10 Aromatics (Unadj.)2.93 J 5.4 1.9 mg/kg MADEP VPH REV 2.1
C5- C8 Aliphatics 3.28 J 5.4 1.9 mg/kg MADEP VPH REV 2.1
C9- C12 Aliphatics 4.93 J 5.4 1.9 mg/kg MADEP VPH REV 2.1
C9- C10 Aromatics 2.93 J 5.4 1.9 mg/kg MADEP VPH REV 2.1
C19-C36 Aliphatics a 3.69 JB 11 2.7 mg/kg MADEP EPH REV 2.1
(a) Re-extract results reported due to QC failure in original extract.
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