MO-8920_40424_CA_20-DAY_20141112_ 20 Day Report

November 12, 2014 Geological Resources, Inc.
Mr. Ron Taraban
NCDENR, UST Section
Mooresville Regional Office
610 East Center Ave
Mooresville, NC 28115
Re: 20-Day Report
The Rock Worship Center
1113 Fordham Road
Charlotte, Mecklenburg County, NC
Incident Number: Pending
GRI Project No: 3605
Dear Mr. Taraban,
Please find enclosed the referenced report for the above mentioned site. If you have any questions, please do not
hesitate to contact Johanna Teschner, P.G. at 704-698-1227.
Sincerely,
Geological Resources, Inc.
thon"nelly
Administrative Assistant
Enclosure
Cc: Pastor Frank Jacobs
file
3502 Hayes Road Monroe, North Carolina 28110
Phone [phone] [phone] • Fax [phone]

20-DAY REPORT
THE ROCK WORSHIP CENTER
1113 FORDHAM ROAD
CHARLOTTE, MECKLENBURG COUNTY
NORTH CAROLINA
INCIDENT NUMBER: PENDING
GRI PROJECT NUMBER: 3605
Prepared for:
Pastor Frank Jacobs
1113 Fordham Road
Charlotte, North Carolina 28208
Prepared by:
Geological Resources, Inc.
3502 Hayes Road
Monroe, North Carolina 28110
November 12, 2014
Johanna M.1'eschner, Y.G.
Project Manager
�J �k..Z.r
Angela Roach
Staff Scientist

SITE INFORMATION
1. Site Identification:
Date of Report: November 12, 2014
Facility ID Number: N/A Incident Number: Pending
Site Name: The Rock Worship Center
Site Address: 1113 Fordham Road
City: Charlotte State: NC Zip Code: 28208 County: Mecklenburg
Description of Geographical Data Point: Calculated from topographic map.
Latitude: 35.21749850 N Longitude: 80.8756155° W
2. Contacts Associated with Leaking UST System:
UST Owner: Rock Worship Center
1134 West Boulevard
Charlotte, North Carolina 28208
UST Operator:
Property Owner:
Primary Consultant:
Rock Worship Center
1134 West Boulevard
Charlotte, North Carolina 28208
Rock Worship Center
1134 West Boulevard
Charlotte, North Carolina 28208
Geological Resources, Inc.
3502 Hayes Road
Monroe, North Carolina 28110
[phone]
Laboratory: Accutest Laboratories - Southeast
4405 Vineland Road, Suite C-15
Orlando, Florida 32811
[phone]
North Carolina Certification No. 573
3. Release Information
Date Discovered: Petroleum odor and soil staining were observed during the UST closure
on November 4, 2014.
Estimated Quantity of Release: Unknown
Cause of Release: Unknown
Source of Release: Unknown
UST Size/Contents: One 550-gallon heating oil UST was removed from the site on
November 4, 2014.

4. Certification:
I, Johanna M. Teschner, a Licensed Geo5for ,,Geological Resources, Inc., do certify that the
information contained in this report is correctratc� �c�l"At 'dghe best of my knowledge.
KA
1 n _
Geological Resour- >Inc.,s licensed to pra'dY2a agbff I gy and engineering in North Carolina. The
certification numbers of the corporation are C-127 and C-2727, respectively.
EXECUTIVE SUMMARY
The site is an active religious facility located at 1113 Fordham Road, in Charlotte, Mecklenburg County,
North Carolina. Land use in the immediate vicinity of the site is residential. Municipal water is available
to the site and surrounding properties. One 550-gallon heating oil UST was removed on November 4,
2014. Based on the field observations, limited excavation activities were conducted. A total of 18.28
tons of petroleum contact soil was removed from the site during the UST closure activities. Additional
information will be included in the Initial Abatement Action Report.

TABLE OF CONTENTS
A. SITE HISTORY AND CHARACTERIZATION..............................................................................I
B. INITIAL RESPONSE AND ABATEMENT ACTIVITIES..............................................................1
C. SOURCE INVESTIGATION..............................................................................................................2
D. SUMMARY AND CONCLUSIONS...................................................................................................3
E. LIMITATIONS............................................................
FIGURES
Figure 1: Site Location Map
Figure 2: Site Map
TABLES
Table 1: UST Owner/Operator Information
Table 2: UST System Information
APPENDICES
Appendix A:
UST-61 Form
Appendix B:
Charlotte Fire Permit Application
Appendix C:
Site Specific Health and Safety Plan
Appendix D:
Liquid Disposal Manifest
Appendix E:
Soil Manifest and Weight Ticket
Appendix F:
UST Disposal Manifest

A. SITE HISTORY AND CHARACTERIZATION
1. UST Owner and Operator Information:
In accordance with the 20-Day Report guidelines, the UST owner and operator information has been
summarized in Table 1.
2. UST System Information:
hi accordance with the 20-Day Report guidelines, the UST system information has been summarized in
Table 2.
3. Non -UST Information:
Not Applicable.
4. Comprehensive Description of the Release:
On November 4, 2014, the 550-gallon heating oil UST was removed. Based on field observations, a
release was suspected at the site. A 24-Hour Release and UST Leak Reporting Form (UST-61 Form) was
submitted to NCDENR on November 11, 2014. A copy of the UST-61 Form is included as Appendix A.
5. Description of the Site Characteristics:
The Rock Worship Center is an active religious facility located at 1113 Fordham Road, in Charlotte,
Mecklenburg County, North Carolina (Figure 1). The adjoining properties are residential. Public water
is available to the site and surrounding properties.
6. Summary of Initial Abatement Actions, Assessment Activities, and Corrective Actions:
Prior to closure, the appropriate officials were notified (i.e. Fire Marshal). A copy of the fire permit
application from the Charlotte Fire Department is included as Appendix B. A copy of the site specific
health and safety plan is included as Appendix C.
B. INITIAL RESPONSE AND ABATEMENT ACTIVITIES
1. Removal of Regulated Substances from UST:
The UST was emptied of fluids prior to commencement of the closure activities. A total of 50 gallons of
fluids were removed from the UST prior to closure. A copy of the liquid disposal manifest is included as
Appendix D.
2. Source Control Actions:
One 550-gallon heating oil UST was removed from the site on November 4, 2014.
3. Contaminant Migration Control Measures:
The potential release was to the subsurface; therefore, no contaminant migration control measures were
necessary.
4. Measures Taken to Mitigate Fire/Safety Hazards:
1

Prior to closure, Charlotte Fire Inspector Kevin Miller was notified. Free product was not encountered
during closure activities. There do not appear to be any immediate fire or safety hazards present as a
result of a release.
5. Measures Taken to Identify and Mitigate Pollution Hazards:
The potential release was to the subsurface; therefore, no mitigation control measures were necessary.
6. Contaminated Soil Storage/Treatment and/or Disposal:
Overburden and contaminated soil from the excavation was loaded into dump trucks for transport to a
permitted disposal facility. A total of 18.82 tons of petroleum contaminated soil was removed from the
site. Copies of the manifest and weight ticket are included as Appendix E.
C. SOURCE INVESTIGATION
1. Investigation Performed to -date to Determine the Source of the Release:
In October 2014, Pastor Frank Jacobs contracted Geological Resources, Inc. to supervise UST closure
activities of one 550-gallon heating oil UST. The UST was removed from the site on November 4, 2014.
A copy of the UST disposal manifest has been included as Appendix F. Petroleum odor and soil staining
was observed in the UST basin. Limited over -excavation activities were conducted. The excavation was
limited to the north by the onsite structure and to the south and east by the concrete stairs and sidewalk.
One soil sample (UST-1-7') was collected underneath the UST and submitted for laboratory analysis of
gasoline -range organic hydrocarbons (TPH-GRO) and diesel -range organic hydrocarbons (TPII-DRO).
Confirmation soil samples CS-1 (10') through CS-5 (10') were collected along the sidewalls and bottom
of the UST basin excavation, at depths of approximately ten feet below ground surface. Confirmation soil
samples were submitted for laboratory analyses of volatile organic compounds using EPA Method 8260,
semi -volatile organic compounds using EPA Method 8270 as well as EPH and VPH using MADEP
Methods.
Soil sample SP-1 was collected from the soil stockpile and was submitted for analyses of TPH-GRO and
TPH-DRO.
All soil samples were collected from the bucket of the backhoe. Analytical data will be included in the
Initial Abatement Action Report (IAAR). Excavation boundaries and soil sample locations are shown on
Figure 2.
2. Ground Water Sampling Performed to -date:
No ground water sampling has been performed at this time.
2

D. SUMMARY AND CONCLUSIONS
One 550-gallon heating oil UST was removed from the site on November 4, 2014. A total of
18.28 tons of petroleum contact soil was removed from the site.
• The site is located in a residential area in the city limits of Charlotte, Mecklenburg County.
Municipal water is available to the site and surrounding properties.
• Additional information will be provided in the IAAR.
E. LIMITATIONS
This report has been prepared for the exclusive use of Pastor Frank Jacobs for the specific application to
the referenced site in Mecklenburg County, North Carolina. The assessment was conducted based on the
scope of work and level of effort specified by NCDENR and with resources adequate only for that scope
of work. Our findings have been developed in accordance with generally accepted standards of geology
and hydrogeology practices in the State of North Carolina, available information, and our professional
judgment. No other warranty is expressed or implied.
The data that are presented in this report are indicative of conditions that existed at the precise locations
sampled and at the time the samples were collected. In addition, the data obtained from samples would be
interpreted as being meaningful with respect to parameters indicated in the laboratory report. No
additional information can logically be inferred from these data.
3

FIGURES

N
LEGEND
------------ UNDERGROUND STORAGE
TANK
— — — EXCAVA77ON AREA
f SO/L SAMPLE LOCA77ON
Syooiy
Rock Worship Center
oxF
Church Building
o
/ �
i
i
CS-5-10'
/ UST-1-7'
i CS-3�10,
Excawtion Area
(Approx. 9' W x 10' L
X 10' Deep)
\
550—Gallon
v
Heating Oil UST
St��tS
SITE MAP
O 1.5 3 6
1113 Fordham Rood
( IN FEET)
Charlotte, Mecklenburg County, NC
Date.* 11111114
1 Drawn by. ECH
Figure: 2
Geological Resources, Inc.
1 inch = 3 ft

TABLES

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APPENDICES

APPENDIX A
UST-61 Form

��� �� slease�� US�Lre� t��l�c�-�►11r�,
For Releases 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
in NC suspected release
(DWM USE ONLY)
Suspected Contamination? (Y/N) Y
Facility ID Number
Incident# - Risk (H,I,L,U)
Confirmed GW Contamination? (Y/N)
Date Leak Discovered i
Received On Received By
Confirmed Soil Contamina'on?(Y/N)
Comm/Non-Commercial?{_
Reported by (circle one): Phone, Fax or Report
Samples Taken?(Y/N)
L Reg/Non-regulated? M
Region
Free Product? (Y/N) N If Yes, State Greatest
J
Thickness
DESCRIPTION
INCIDENT
Incident Name: �QC1� xj'Y �'11 �, cat tkJ(
1\,j,�,,W y
Address: t t j -- �UCa.` 1 QO®-
County: m@b—/\wiIo�
City/Town: CJ ay kawc
Zip Code:L�Q Ej
Regional Office (circle one): Asheville, Mooresville, Fayetteville,
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): 3S, 2_jqLjq1g5 Longitude (decimal degrees) : VC), g :J J 151,5
Obtained by:
❑ GPS
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)
�A Topographic map
❑ GIS Address matching
„ to 4.. (AQ6V 1fi cAokor and
._;li,.,tom, On O
SUA s_zc�
❑ Other
❑ Unknown
Describe location: V.K'5t
-(a
aF'�sY{e,�`-Pll'c�cr�
HOW RELEASE WAS DISCOVERED (Release Code)
(Check one)
❑ Release Detection Equipment or Methods ® Visual/Odor ❑ Groundwater Contamination
During UST Closure/Removal ❑ Water in Tank ❑ Surface Water Contamination
❑ Property Transfer ❑ Water Supply Well Contamination ❑ Other (specify)
SOURCE OF CONTAMINATION
Source of Release Cause of Release Type of Release Product Type Released
(Check one to indicate primary (Check one to indicate primary (Check one) (Check one to indicate primary product type
source) cause) released)
Tank ❑Spill 5LPetroleum ❑ Gasoline/Diesel/ ❑ Diesel/Veg. Oil
Kerosene Blend
❑ Piping ❑ Overfill ❑ Non -Petroleum 1A ❑
Heating Oil Vegetable Oil 100%
❑ Dispenser U Corrosion ❑ Both ❑ Other Petroleum ❑ El - E20
❑ Submersible Turbine Pump ❑ Physical or Mechanical Products
❑
❑ Delivery Problem Damage Location ❑ Metals E21 - E84
❑ ❑ E85-Egg
❑ Install Problem (Check one) Other Inorganics
❑ Other ❑
❑Other ❑Facility Other Organics ❑ Ethanol 100%
❑ Unknown
❑ Unknown ❑ Residence ❑ E01 -E09
Definitions presented on reverse Definitions presented on reverse I W Other
Ownership
1. Municipal 2. Military 3. Unknown 4. Private 5. Federal 6. County 7. State
Operation Type
1. Public Service 2. Agricultural 3. Residential ccEducationlRelig. 5. Industrial 6. Commercial 7. Mining
UST Form 61 (02108) 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.
OWNER
BUST"S'YSTEM
UST Owner/Company QOck. wcxshl� tJU' Ae-le
6
Point of Contact
P r-ranK
Address
11314 w°5� BouleUa�rci
City
CkaYlb e
State
NC,
Zip Code
28206
Telephone Number
+0y-q3U-,EiB Ll-
UST SYSTEM OPERATOR
UST Operator/Company
Address
SKMf, 65
City
State
Zip Code
Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
Address
City
State
Zip Code
Telephone Number
Draw Sketch of Area (showing two major road intersections) or Attach Map
Person Reporting lncimmLl} tawa-r
ipany ' A1..�rCo C'...
Telephones Number Xcl-8q5-4610
Title
Address MZ - (5 .� nfT2,l - Zvi IC>
Dale
UST Form 61 (02/08)
Page 2 of 2
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

APPENDIX B
Site Specific Health and Safety Plan

GEOLOGICAL RESOURCES, INC.
Site Specific Health and Safety Plan
1.0 General Information:
a. Project name: The Rock Worship Center
b. Location: 1113 Fordham Road, Charlotte, NC
c. Phone number:
d. GRI Project number: 3605
2.0 Project Organization:
a. Field Manager: Justin Radford
b. Project Manager: Johanna Teschner
3.0 Safety Plan Preparation:
a. Prepared by & date: Johanna Teschner 11/03/2014
b. Reviewed/approved by & date:
4.0 Site History and Description:
a. Type of site: Private Residence
Site/project description: heating oil tank removal
b. Results of previous surveys:
c. Waste types:
x Liquid
x Solid
X Sludge
—Gas/vapors
Other
d. Hazardous characteristics: (check)
_ Toxic
x Flammable/Volatile
Ignitable
_ Corrosive
_ Reactive
Explosive (No open flames of any type)
e. Hazardous evaluation: (known or suspected)
Material Quantit (if known)
IDLH
1

.}
5.0 Site Organization and Control:
a. Work areas identified: entire site
b. Support area established: entire site
c. Entry and escape routes identified:
d. Site map attached: Figure 2
6.0 Job Activities in Work Plan:
a. Types of activities planned: (check)
X Tank (UST): Excavation
X Soil: Excavation X
Disposal _X_
Treatment
_Soil borings
_Well installation
_Water treatment
_Water sampling
_Other (specify):
7.0 Education and Training:
All Geological Resources site personnel have completed OSHA HAZWOPER training.
8.0 Air Monitoring:
If, in the opinion of the site supervisor, petroleum hydrocarbon vapor concentrations are
excessive, site activities will cease until petroleum hydrocarbon vapor concentrations
diminish to acceptable levels.
9.0 Equipment:
FID/PID
Combustible gas indicator
02 meter
Other:
10.0 Personnel Protection Requirements:
a. Job Activity: supervising tank removal, soil sampling
Level: D
Equipment required: Disposal latex gloves.
11.0 Safety Equipment:
a. First Aid: First aid kit in vehicle and readily available.
b. Fire Fighting: Fire extinguisher in vehicle and readily available.
c. Communications: Verbal and hand signals.

12.0 Decontamination Procedures:
a. Work activities: supervising tank removal, soil sampling, well install, ground water
sampling
b. Level protection: D
c. Decontamination solutions: Alconox/H2O
d. Procedures: personnel and hand tools/equipment will be decontaminated by washing
with an Alconox/H2O solution.
13.0 Contingency Plan:
a. Emergency Assistance:
1) 911
b. National or Regional Sources of Assistance:
1) Geological Resources, Inc.
[phone]
2) Chemtrec (24 Hours)
1-800-424-9300
3) Bureau of Explosives (24 Hours)
1-202-293-4048
4) National Response Center, NRC
1-800-424-3802
(Oil/Hazardous Substances)
5) DOT, Off. OfHaz. Operations
1-202-426-0656
DOT (Regulatory Matters)
1-202-426-9280
14.0 Signatures:
This plan has been reviewed by all on -site personnel and all provisions are clear
(signatures required).
Project Manager:
1
Field Manager: r �'
Other personnel: G j7A74

15.0 Amendments:
a. Site Specific Health and Safety Plans are based on information available at the time of
plan preparation. Unexpected conditions may arise. It is important that personal
protective measures be thoroughly assessed prior to and during the planned activities.
Unplanned activities and/or changes in the hazard status should initiate a review of this
plan and may result in major changes to it.
b. Changes in the hazard status or unplanned activities are to be submitted on
"Amendment to the Site Specific Health and Safety Plan" which is included as page 5 of
this plan.
c. Amendment must be approved by the Project Manager prior to implementation of the
amendment.
AMENDMENT TO THE SITE SPECIFIC HEALTH AND SAFETY PLAN
A. Changes in field activities or hazards:
B. Proposed amendment:
C. Approval:
Proposed by:
Approved by:
Amendment number:
Amendment effective date:
n
date
date

APPENDIX C
Mecklenburg County Fire Permit Application

CHARLOTTE FIRE DEPARTMENT
FIRE PREVENTION BUREAU
Tank Removal and Safeguarding Permit Application
This is the company name and mailing address of the tank removal company.
Name(,LtSCr)C"fjt
Address: G/(1 j l A,y ES /Z b City/State:M p A) f_G L= N C Zip Code: rag)10
Phone Number: (-7t)4 ) ?tl5- _ qo/ o Cell Number: ( )
Location and Type of Project
This is the facility name and address of the tank removal project. lfvacant property, indicate "Vacant"/or facility name.
Facility Name:'Tiiel2c,r—k l t 6tZ5HlPCIEP IZ�ress: W3 F—r, -00A)AA
Type of Project: ,iC Tank Removal Tank Abandonment Both A/G: B/G: /V
Tank Information
If more than 4 tanks, complete a separate sheet.
Tank 1) Product: t(EA I M6-OIL Size: ! CJa 4r Tank 2) Product: Size:
Tank 3) Product: Size: Tank 4) Product: Size:
Tanks Transported To:
Responsible Applicant
Name: 10-W 'h AI& C, G—llz r-J Title: ?(-0 3 ecT M �-p,1StGle i
Signature: Date: P t' / Z �' /
I certify th the information provided and ained herein is true and accurate to the best of my knowledge. The issuance of a
permit all not be deemed as approval to violate any provisions of the North Carolina State Fire Code. The code official has the
righ o inspect the site to ensure compliance with provisions of the fare code, and to issue a Stop Work Orderfor unsafe practices.
NOTE! A site plan of the job site shall be submitted with this application
Return the completed and signed application, site plan, and check to: Pni i[-�> !3y
Charlotte Fire Department - Fire Prevention Bureau
441 Beaumont Avenue
Charlotte, North Carolina 28204
Phone: [phone] Facsimile: 704-336-5190 o 0 z\
Check )inclosed Payable to "The City of Charlotte"
If you wish to pay by credit card, contact the Fire Prevention Bureau Of
lee to provide necessary information.
Permit Code: 16 Fee: $ Permit No.
Check No.
Issued by Inspector:
Information Collected By:
Entry Date: / /
Issue Date: /
Emp. #:
Entered By:

APPENDIX D
Liquid Disposal Manifest

APPENDIX E
Soil Manifest and Weight Ticket

f I
17
Environmental Soils Inc.
j � F
PO Box 295 • Lattimore, NC 28059
Phone [phone] • Fax [phone]
t Non -Hazardous Waste Manifest # 44858
Date t;? t �' Load Number
i
(numbered sequentially as trucks are dispatched)
ENVIRONMENTAL CONSULTANT: t 7 c • W, L ;'j
r
Contact: '''¢`};J'N -:' i1,iiT � Phone
ti`.. / a U Fax:' ••`l
GENERATOR. t
Address: County: ^, 44V: �it��t-i
Contact: ": rt - \ ,..: '� Phone:7_<•`Ir`; "al -joc3ri
WASTE ORIGINdTIONPOIIVT Complete Address: I Me, ti, ocu 7,�r •°= ' ` ' `''
Class &Type;of Contaminate in soil pun/ 1-1i1n�
SOURCE OF CONMMIN1iTION.• (ex. UST or other source) NuA-rj'1VCi Of C6
'
GENERATORS CERTIFICATION OF WASTE CONSTITUENTS: In lieu ofsubmitting analytical data methods
8240 and 8270) verifying thatthe waste in question does not contain organic constituents other than those which would
normally appear in analysis of virgin petroleumjiroduct residue, I am submitting this Certificate'of Waste
Constituents. I certtify thatl am familiar with the source of contamination of the soil and further certify the source;; to
the best of my knowledge, contains no contaminants other than that listed above. / p� %
Generators.Sgnature;t/>ri d �A1 %3 ' Fi t ^'7 Date: `" /
TRANSPOATER s l Ali
Contact: Phone: 1
As the carrier, I certify that the materials described above being shipped under this non -hazardous materials
manifest are properly classified, packaged, labeled, secured, and are in proper condition for transport, in commerce
under the applicable reguiatio s governing ansportation, and'I hereby receive this material for delivery to the
facility designate:
Carrier Signature, i .,� _ec� '� M. Date:
TRUCK #: t yT1G VOLUME:
TRUCK DRIVER SIGNA'T'URE: t DATE:
i
DESTINATION.• Environmental Soils Inc. 910 Crowder. Rd, Shelby, NC 28150 Dedicated Land Application ..
Site Permit #SR0300038
I certify that the carrier has delivered the materials described above to this facility, and Thereby accept this;material
for -treatment and/or disposallin a manner that has been authorized bythe State of North Carolina. '
e, 1
Facility Signature' Date:
' Signature; Date.
Company Name , - Title:
White/Facility Oanary/Invoice Pink/Carrier Goldenrod/Generator M

APPENDIX F
UST Disposal Manifest

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