WS-96392_97328_CA_UST-62_20240424

UST-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) ___
Confirmed GW Contamination? (Y/N) ___
Confirmed Soil Contamination ?(Y/N) ___
Samples taken?(Y/N) ___ Free product? (Y/N) ___
If Yes(free product), state greatest thickness: _____feet
Release discovered
(time/date):______________
_______________________
INCIDENT DESCRIPTION
Incident Name:
Address (street number/name):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:
Describe suspected or confirmed release (nature of release, time/date of release, quantity of release, amount of free
product):T GPS
T Electronic topographic map
T GIS Address matching
Describe initial response/abatement (time/date release stopped, cleanup begun/completed, quantity of product
soil removed, confirmation sampling):
T Other
T Unknown
Describe impacted receptors: Describe location:
HOW RELEASE WAS DISCOVERED (Release Code)
(Check one)
T Observation of Release at Occurrence
T Visual or Olfactory Evidence
T Soil Contamination
T Groundwater Contamination
T Water Supply Well 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 petroleum product
type released)
T AST (tank)
T AST Piping/ Dispenser
T AST Delivery Problem
T OTR Vehicle Tank
T OTR Bulk Transport Tank
T RR Bulk Transport Tank
T Transformer
T Unknown
T Other ______________
Definitions presented on reverse
T Spill (Accidental)
T Spill (Intentional)
T Corrosion
T Physical or Mechanical
Damage
T Equipment Failure
T AST Overfill
T AST Installation Problem
T Unknown
T Other ______________
Definitions presented on reverse
T Petroleum
T Both Petroleum
& Non-Petroleum
Location
(Check one)
T Facility
T Residence
T Highway/Road
T Railway
T Other
T Gasoline/ Diesel/
Kerosene
T E11 – E20
T E21 – E84
T E85 – E99
T Ethanol 100%
T Diesel/Veg. Oil
Blend
T Vegetable Oil 100%
T Heating Oil
T Waste Oil
T Mineral Oil-no
PCBs
T Mineral Oil-PCBs
T Other Petroleum
Products ________
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
Guidance presented on reverse
UST Form 62 (04/10) Page 1 of 2
S&A Fleet Spill
I-85 Southbound Near Exit 111 Randolph
Archdale 27263
35.9026829 -79.9550857
On 04/20/24, a truck traveling southbound on I-85 struck debris on the road that punctured
its saddle tank. The truck pulled over and sat on the shoulder and leaked approximately 75-100 gallons
Approximately 75-100 gallons of diesel fuel were spilled.
Victory Environmental responded the same day by putting out booms and absorbent material and covering the area with plastic.
On 04/22/24 Victory Environmental excavated the spill area while Pyramid Environmental collected 11 confirmatory samples.
None
Google MapsX
Near Exit 111 I-85
southbound
X
X
X X
X
of diesel fuel.
Y
N
YY N
N/A
4/20/24 7:00AM
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)
UST Operator/Company Address
City State Zip Code Telephone Number
LANDOWNER AT LOCATION OF INCIDENT
Landowner Address
City State Zip Code Telephone Number
Draw Sketch of Area or Provide Map (showing incident site, location of release, two major road intersections, potential
receptors)
Attach sketch or map to form.
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) Page 2 of 2
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
None
None
None
S&A Fleet
See Attached Map
Brian Mahan Pyramid Environmental & Engineering
Brian Mahan 503 Industrial Ave, Greensboro, NC 4/23/24
(336) 335-3174
1345 Trail Road
Belton SC 29627 [phone]
Same as Above
Same as Above
NCDOT
4/23/24, 10:59 AM Randolph County GIS
https://gis.randolphcountync.gov/randolphts/1/1
Randolph County,yy NC
Disclaimer:Thismapwascompiledfromrecordeddeeds,plats,andotherpublicrecordsanddata.
Usersofthisdataareherebynotifiedthattheaforementionedpublicinformationsourcesshouldbe
consultedforverificationoftheinformation.RandolphCounty,yy itsagentsandemployeesmakeno
warrantyastotheaccuracyoftheinformationonthismap.
Map Scale
1 inch =141 feet
4/23/2024
Approximate Spill
Location
4/23/24, 10:52 AM 450 W Hanes Mill Rd to Archdale, North Carolina - Google Maps
https://www.google.com/maps/dir/450+W+Hanes+Mill+Rd,+Winston-Salem,+NC+27105/35.9028021,-79.9550116/@36.0404795,-80.1937344,11z/am…1/2
Map data ©2024 Google 2 mi
450 W Hanes Mill Rd
Winston-Salem, NC 27105
Get on US-52 S from State Rte 1672
1. Head northeast toward State Rte 1672
2. Turn left toward State Rte 1672
3. Turn right toward State Rte 1672
5. Turn right onto State Rte 1672
6. Turn left to merge onto US-52 S
Continue on US-52 S. Take I-74/US-311 to I-85 S in Archdale
7. Merge onto US-52 S
Drive 35.3 miles, 38 min450 W Hanes Mill Rd, Winston-Salem, NC 27105 to
Archdale, North Carolina
4/23/24, 10:52 AM 450 W Hanes Mill Rd to Archdale, North Carolina - Google Maps
https://www.google.com/maps/dir/450+W+Hanes+Mill+Rd,+Winston-Salem,+NC+27105/35.9028021,-79.9550116/@36.0404795,-80.1937344,11z/am…2/2
8. Continue onto I-285/US-52 S
9. Take exit 107A to merge onto I-40 E toward
Greensboro
10. Use the right 2 lanes to take exit 196 for I-74 E
toward US-311 S/High Point
11. Continue onto I-74/US-311
Archdale
North Carolina
371 ft
2.5 mi
0.7 mi
18.6 mi
2.9 mi