Appendices Appendix A – Report Formats 67 1. Site Check Report 68 2. Notice of Intent: UST Permanent Closure or Change-in-Service Form (UST-3) 73 3. 24-Hour Release and UST Leak Reporting Form (UST-61) 75 4. 20-Day Report 78 5. UST Closure Report (following UST-12 format) and Site Investigation Report for Permanent Closure or Change-in-Service of UST (UST2A or UST-2B) 82 6. Initial Abatement Action (Site Check, UST Closure with UST-2 Form, Excavation, Post-Excavation Soil Contamination Assessment) Report 89 Appendix B – Reporting Tables 98 1. Table B-1 Site History – UST/AST System and Other Release Information 99 2. B-2: Site History – UST/AST Owner/Operator and Other Responsible Party Information 100 3. Table B-3: Summary of Soil Sampling Results 101 4. Table B-4: Summary of Groundwater and Surface Water Sampling Results 102 5. Table B-5: Private/Public Water Supply Well and Other Receptor Information 103 6. Table B-6: Property Owners/ Occupants 104 7. B-7: Monitoring and Remediation Well Construction Information 105 8. B-8A: NAPL Recovery Information 106 9. Table B-8B: Cumulative Volume of NAPL Recovered from Site 106 10. Table B-9: Current and Historical Groundwater Elevation and FP Thickness 107 Appendix C – UST Systems: Regulated or Not Regulated 15A NCAC 2N 108 Appendix D – Collecting Soil Samples 111 Appendix E – Disposal of Contaminated Soil and Groundwater 112 Appendix F – Guidelines Pertaining to Contaminant Sources other than USTs 118 Appendix A – Report Formats Site Report Notice of Intent: UST Permanent Closure or Change-in-Service Form Form) 24-Hour Release and UST Leak Reporting Form (UST 61 Form)
Initial Abatement Action (Site Check, UST Closure with UST-2 Form, Excavation, Soil Contamination Assessment) Report In addition to reporting initial response and abatement actions and assessment actions, and presenting an initial site characterization, when a release has been discovered, this newly-created Initial Abatement Action Report must fulfill the requirements for the following individual reports: Site Check Report (Section E), UST Closure Report (UST-12) with UST-2 Form (Section F), Post-Excavation Soil Contamination Assessment Report (Section J), and Free Product Recovery Report (Section G). If needed, check with your regional office to determine which report format is required. Complete Sections A-N, as required, including the sections specifically designated for the reports you have indicated. The Initial Abatement Action Report must be submitted to the appropriate regional office within 90 days following discovery of release. Site Information Site Identification Date of Report: Site Risk: Facility I.D.: UST Incident Number (if known): Site Name: Street Address: City/Town: Zip Code: County: Description of Geographical Data Point (e.g., diesel fill port): Location Method (GPS, topographical map, other): Latitude (decimal degrees): Longitude (decimal degrees): 2. Information about Contacts Associated with the Leaking UST System (Addresses must include street, city, state, zip code and mailing address, if different) UST/AST Owner: Email: Address: Tel: UST/AST Operator: Address: Tel: Property Owner: Email: Address: Tel: Property Occupant: Email: Address: Tel: Consultant/Contractor: Email: Address: Tel: Analytical Laboratory: State Certification No: Address: Tel: 3. Information about the Release Date Discovered: Estimated Quantity of Release: Cause of Release: Source of Release (e.g., Dispenser/Piping/UST): Sizes and Contents of Tanks or Other Containment from which the Release Occurred: Excavation
Table B-7: Monitoring and Remediation Well Construction Information Revision Date: Incident Number and Name: Facility ID#: Well ID Latitude/ Longitude* (In Decimal Degrees) Well Construction Details Date Water Level Measured (mm/dd/yy) Depth to Water from Top of Casing (ft.) NAPL Thickness *** (ft.) Ground- water Elevation ***(AMSL) Date Installed (mm/dd/yy) Well Diameter (in.) Casing Depth (ft. BGS) Screened Interval (x to y ft. BGS) Total Depth (ft. BGS) Top of Casing (ft.) ft BGS = feet below ground surface AMSL = Above Mean Sea Level * The location must be sufficiently accurate and precise to allow easy recovery of lost or damaged wells. ** Reference Point for Elevation Measurements , Assumed Elevation: ft. *** If NAPL is present in a well, groundwater elevation is calculated by: [Top of Casing Elevation - to Water] + [NAPL thickness x 0.8581]
Table B-8A: NAPL Recovery Information Revision Date: Incident Number and Name: Facility ID#: Date (m/dd/yy) Well ID # Product Type (gas, diesel, etc.) NAPL Recovery Method* Product Thickness before Recovery (feet) Product Thickness after Recovery (feet) Amount of Vaporized Product (gallons) Amount of Liquid (Water + Product) (gallons) Amount of Liquid Product (gallons) Total Amount of Product Recovered (gallons) (Present all calculations in an attachment) * Bailing, Skimming, Aggressive Fluid Vapor Recovery, Mobile Multiphase Extraction, etc, Table B-8B: Cumulative Volume of NAPL Recovered from Site Date of Recovery (m/dd/yy) Volume Recovered from Site During Current Recovery Event (gallons) Cumulative Total of Volume Recovered to Date from All Recovery Events (gallons)
Table B-9: Current and Historical Groundwater Elevations and NAPL Thickness Revision Date: Incident Number and Name: Facility ID#: Well ID # Top of Casing Elevation (AMSL) Screened Interval (top of screen, bottom of screen) Date Measured (mm/dd/yy) to Water* (Uncorrected) (feet) NAPL Thickness (feet) Depth to Water* (Corrected for NAPL Thickness) (feet) Groundwater Surface Elevation** (AMSL) * to Water is measured from Top of Casing ** If NAPL is present in a well, groundwater elevation is calculated by: [Top of Casing Elevation - Depth to Water] + [NAPL thickness x 0.8581]