MO-9517_40954_CA_UST-61_20190626_24-Hr Release and UST Leak Reporting Form

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
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 Unknown
Incident # Risk (H,I,L,U)
Confirmed GW Contamination? (Y/N) N
Date Leak Discovered 6-21-19
Received On Received By
Confirmed Soil Contamination ?(Y/N) Y
Comm/Non-Commercial? Non -Comm
Reported by (circle one): Phone, Fax or Report
Samples Taken?(Y/N) Y
Reg/Non-regulated? Non -Regulated
Region
Free Product? (Y/N) N If Yes, State Greatest
Thickness
INCIDENT DESCRIPTION
Incident Name: City of Charlotte Property
Address: 518 W. 4th Street
County: Mecklenburg
Regional Office (circle one): Asheville, Mooresville, Fayetteville,
City/Town: Charlotte
Zip Code: 28202
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): 35.230870 Longitude (decimal degrees) :-80.848122
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
❑ Topographic map
On behalf of NCDOT, Hart & Hickman (H&H) oversaw removal of one heating oil UST from the site on 6-17-19. The
❑ GIS Address matching
UST was estimated to be —2,000-gallons in capacity. Elevated PID readings of UST closure samples indicated a
® Other Google Earth
potential release beneath the UST. Laboratory analytical results received by H&H on 6-21-19 confirmed a release
❑ Unknown
beneath the UST. Concentrations of TPH-DRO (up to 7,230 mg/kg) were detected in samples collected from beneath
Describe location:
the UST. Approximately one dump truckload of overburden soil was removed from the tank pit for proper disposal
during UST closure activities.
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) Lab data
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 0 Petroleum ❑ Gasoline/ Diesel/ ❑ Diesel/Veg. Oil
Kerosene Blend
❑ Piping ❑Overfill ❑Non -Petroleum
® Heating Oil ❑ Vegetable Oil 100%
❑ Dispenser ❑ Corrosion ❑ Both ❑ Other Petroleum ❑ E10 — E20
❑ Submersible Turbine Pump ❑ Physical or Mechanical Products
❑
E21 — E84
Damage Location ❑ Metals
❑ Delivery Problem ❑ E85 E99
❑
oOther Inorganics —
❑ Install Problem (Checkne )
❑ Other ❑ Other ❑ Other Organics ❑ Ethanol 100%
❑Facility
❑ Unknown
® Unknown ❑ Residence ❑ E01 — E09
Definitions presented on reverse I Definitions presented on reverse I ® 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 4. Education/Relig. 5. Industrial 6. Commercial 7. Mining Unkown
UST Form 61 (02/08) 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
Orphan UST
Point of Contact
Address
City
State
Zip Code
Telephone Number
UST SYSTEM OPERATOR
UST Operator/Company
Address
Orphan UST
City
State
Zip Code
Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
Address
City of Charlotte
600 East 4th Street
City
State
Zip Code
Telephone Number
Charlotte
NC
28202
704-651-4366
Draw Sketch of Area (showing two major road intersections) or Attach Map
See Attached Map
Person Reporting Incident David Graham
Company Hart & Hickman PC - Agent for NC DOT
Telephone Number 704-586-0007
Title Senior Project Geologist
Address 2923 S. Tryon St., Suite 100, Charlotte, NC 28203
Date 6-26-19
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

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CITY OF CHARLOTTE PROPERTY
BOUNDARY (PARCEL 07315110)
FOOTPRINT OF NEW GREYHOUND
FACILITY
....... FORMER 2,000-GALLON HEATING OIL
;...... UNDERGROUND STORAGE TANK
LOCATION
• LIGHT POLE
NOTES:
1. BASEMAP PROVIDED BY NCDOT (5/2018).
APPROXIMATE
0 40 80
SCALE IN FEET
SITE MAP
Ra1rcT CITY OF CHARLOTTE PROPERTY
518 W. 4TH STREET
CHARLOTTE, NORTH CAROLINA
2923 South Tryon Street -Suite 100
hart " h i e k m a n Charlotte, North Carolina 28203
704-586-0007(p) 704-586-0373(�
SMARTER ENVIRONMENTAL SOLUTIONS License # C-1269 / #C-245 Geology
DATE: 6-25-19 REVISION NO. 0
JOB NO. ROW-516 FIGURE NO. 1

Beverly, Trudy
From: David Graham <[e-mail]>
Sent: Thursday, June 27, 2019 10:02 AM
To: Beverly, Trudy
Subject: RE: [External] NC DOT State Project P-5705B - 24-Hour Release Form
External email. Do not click links or open attachments unless you verify. Send all suspicious email as an
�fftachment to [e-mail]
Will do, thanks
From: Beverly, Trudy[mailto:[e-mail]]
Sent: Thursday, June 27, 2019 10:01 AM
To: Bowser, Daniel P <[e-mail]>; David Graham <[e-mail]>
Subject: RE: [External] NC DOT State Project P-5705B - 24-Hour Release Form
Dan —Thanks for forwarding the UST-61.
Hi David,
I handle nonregulated sites in Mecklenburg county. Please send future communications related to this release
to my attention.
Thanks and have a great day,
Trudy
DE
Nf7RTH �:ARc�I INA i
Department of environmental Ouality
Tr ift L.G.
Wank Qrul6a Elopmunm dEw4immund Qwft
LOT &-cW% Ymn'.' k RedmW Offm
(: 235,2182 (O
lfuriy. NOV
Email correspondence to and from this address is subject to the
Narlt) Caiolina Public Records Law and may be disclosed to INid parries.
Office Mailing Address:
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Branch's Underground Storage Tanks Website Address: https://deq.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: https://deq.nc.,gov/about/divisions/waste-management/ust/ast-
program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
https:Hdeq.nc.gov/about/divisions/waste-management/waste-management-rules-data/waste-mana eg ment- ig s=maps
File Review Procedures:
https:Hdeq.nc.,gov/about/divisions/waste-management/ust/file-review-procedures#mooresvill e-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):

hl�2s:Hedocs.deg.nc.jzov/WasteManagement/Search.asp
Document Submittal & UST File Names for Laserfiche Policies:
httns:Hfiles.nc. eov/ncdea/Waste%20Manaizement/DWM/UST/Corrective%20Action/Electronic%20Document%20Submittal
%20Memo%20Update.12df
httt)s:Hfiles.nc. eov/ncdea/Waste%20Manaeement/DWMIUST/Corrective%20Action/UST%20file%20names%20for%20Las
erfiche.docx
From: Bowser, Daniel P
Sent: Thursday, June 27, 2019 9:13 AM
To: Beverly, Trudy <[e-mail]>
Subject: Fwd: [External] NC DOT State Project P-5705B - 24-Hour Release Form
Dan Bowser, PG
NCDEQ
UST Section
Corrective Action Branch
From: David Graham <[e-mail]>
Sent: Thursday, June 27, 2019 8:21:44 AM
To: Bowser, Daniel P
Cc: Parker, Cyrus F; Box, Gordon H; Cox, Ashley B; Pierotti, Doug; Matt Bramblett
Subject: [External] NC DOT State Project P-5705B - 24-Hour Release Form
External email. Do not click links or open attachments unless you verify. Send all suspicious email as an
lachment to [e-mail]
Dan
Attached is a 24-Hour Release notification form for a heating oil tank that we recently removed on behalf of NC
DOT from 518 W. 41" Street in Charlotte, NC. We will prepare a report to document the UST closure activities.
If you have any questions please let me know. Thanks
David Graham, PG Senior Project Geologist
Hart & Hickman, PC
2923 S Tryon Street, Suite 100 • Charlotte, NC 28203
Direct: 704-887-4630 • Mobile: [phone]
www.hafhickman.com I no 0