MO-28677_47913_CA_UST-61_20210628_24-Hour 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 N/A
Incident # Risk (H,I,L,U)
Confirmed GW Contamination? (Y/N) N
Date Leak Discovered 6/28/21
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 -Reg.
Region
Free Product? (Y/N) N If Yes, State Greatest
Thickness N/A
INCIDENT DESCRIPTION
Incident Name: Atlantic American Property
Address: 502 S. Main Street
county: Cabarrus
Regional Office (circle one): Asheville, Mooresville Fayetteville,
City/Town: Kannapolls
Zip Code: 28081
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): N 35.49012888' Longitude (decimal degrees) : W 80.628239330
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
❑GISAddress matching
❑Other
❑Unknown
Describe location:
-Soil contamination confirmed by laboratory result of soil sample collected
by hand auger on 6/21/21 (TPH results attached)
-No supply wells within 150 feet of source area
-Notice of Residual Petroleum signed by RP to be submitted
-UST to be removed in next few weeks
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) Hand Auger
SOURCE OF CONTAMINATION
Source of Release Cause of Release Type of Release Product Type Released
(Check primary source) (Check primary cause) (Check one) (Check primary product type released)
® Tank ❑ Spill ® Petroleum ❑ Gasoline/ Diesel/ ❑ Diesel/Veg. Oil
❑ Piping ❑ Overfill ❑ Non -Petroleum Kerosene Blend
❑ Dispenser ® Corrosion ❑ Both ® Heating Oil ❑ Vegetable Oil 100%
❑ Other Petroleum ❑ El0 — E20
❑ Submersible Turbine Pump ❑Physical/Mechanical
Location Products
❑ ❑ Delivery Problem Damage (Check one) Metals ❑ E21 — E84
❑ Install Problem ❑ E85 — E99
❑ Spill Bucket ❑ Other Inorganics
❑ ❑Other [:]Facility[:]Ethanolnol 100%
Other ❑ Other Organics
❑ Unknown ®Residence ❑ E01 — E09
❑ Unknown
❑Other
Definitions presented on reverse
Definitions presented on reverse
Ownership
1. Municipal 2. Military 3. Unknown O Private 5. Federal 6. County 7. State
Operation Type
1. Public Service 2. Agricultural 0 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 0No 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 Atlantic American Properties, Inc.
Point of Contact
Address
Justin Kies
226 Oak Avenue
City
State
Zip Code
Telephone Number
Kannapolis
NC
28081
[phone]
UST SYSTEM OPERATOR
UST Operator/Company
Address
Unknown
City
State
Zip Code
Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
Address
Atlantic American Properties, Inc.
226 Oak Avenue
City
State
Zip Code
Telephone Number
Kannapolis
NC
28081
[phone]
Draw Sketch of Area (showing two major road intersections) or Attach Map
See Attached Map
Person Reporting Incident Ben Robinson
Company Paragon Environmental Consultants Inc.
Telephone Number(336) 669-6037
Title Geologist
Address P.O. Box 157, Thomasville, NC 27361
Date 6/28/21
UST Form 61 (02/19)
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 till
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

Mentech Inc.
A4�
Environmental Laboratories
Laboratory Certification #165
Client Name Paragon Environmental Consultants. Inc. Report Date 06/25/21
Project Name P-2148 Sample Matrix Soil
Site Location 502 S. Main Street Analyst CWL
Total Petroleum Hydrocarbons
Meritech
Client
Analysis
Date
Date
Dilution
%Dry
Surrogate
Results
Date
ID #
Sample ID
Performed
Sampled
Extracted
Factor
Solids
Recovery
(m /k
Analyzed
06232134
T1-6'
3550
06/21/21
06/24/21
100
80%
*"
223600
06/24/21
Hydrocarbon Ranges Units of Measure
Sample Weight: DRO=30.Og GRO=10.Og
DRO - 3550/8015C mg/kg
GRO - 5030/8015C mg/kg
TPH Surrogates/Spikes
DRO/3550: Chrysene/Diesel
Reporting Limit for 3550 and 5030 = <10.0 mg/kg
GRO/5030 Bromochlorobenzene/Gasoline
Was method blank below reporting limit?
5030 Lab Spike Recovery = N/A
(YES) NO - Details Attached
5030 Lab Spike Duplicate Recovery = N/A
Spike Recovery Acceptance Range/Conc,
5030 Matrix Spike Recovery = N/A
Diesel 40 - 140% 300 ug/ml
5030 Matrix Spike Duplicate Recovery = N/A
Gasoline 70 - 130% 40 ug/ml
3550 Lab Spike Recovery = 85%
Surrogate Recovery Acceptance Range/Conc,
3550 Lab Spike Duplicate Recovery = 90%
Chrysene 40 - 140% 100 ug/ml
Bromochlorobenzene 70 - 130% 100 ug/ml
3550 Matrix Spike Recovery = 60%
3550 Matrix Spike Duplicate Recovery = N/A
5030 LCS/LCSD RPD = N/A
5030 MS/MSD RPD = N/A
3550 LCS/LCSD RPD = 5.71
3550 MS/MSD RPD = N/A
RPD Limit = 15
* Surrogate/Spike/RPD exceeds limits.
** Surrogate/Spike diluted out/matrix interference.
TPH Report Revision 05l05/09
I hereby certify that I have reviewed and approve these data.
Reviewed By �/,�r/I�

8/9/18
Chain of Custody Record (COC)
NPDES#:
M ERITECH, INC,
Client: Phone:
Address: Fax:
ENVIRONMENTAL LABORATORIES0%1
EnvkonmPe'nfol 'isa'"' Inc. Email: X VG�Qay1Ll1
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Project: S62'LS. Main S
Reidsville INC 27320 Fax: [phone]
P.O.#: - 2�'L g
Email: [e-mail]
Attention: �Qln�i(jnol�E Turn Around Time*
*RUSH work
How would you like your report sent?
needs prior approval,
www.meritechiabs.com
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Circle all that apply: Email( referred), Fax, Mall Stcl 10da s)
3-5 Days zrs
Sampling Dates & Times
son Taking Sample / rint : I�mjn ,
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Lab Use Only
Sample Location and/or ID #
Start End
o p? #of Test(s) Required
Grab?
On
on Ice? pH OK?
Date
Time/
Date
Time
Cont.
/ No Cl OK?
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Temperature Upon
Method of
*** Dechlorination (<0.5 pm) of Ammonia, Cyanide, Phenol and TKN samples must be done in the field prior to preservation. ***
Receipt: t L
-
Shipment:
Comments:
Compositor #
UPS
Jug #
El Fed Ex
Are these results for regulatory purposes? Yes X
No ❑ Repot results in: mg/L ❑ mg/kg ® ug/L ❑
Hand Delivery
linquished by:_ Da : Time:
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Time:
❑ Other
el quish by' te: Timed Received by: Date:
Time:
Relinqu sh d by: Date: Time:
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Beverly, Trudy
From: Beverly, Trudy
Sent: Tuesday, June 29, 2021 6:35 AM
To: Ben Robinson
Subject: RE: [External] Atlantic American Property UST-61
Received. Thanks Ben!
Have a great day,
Trudy
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
��DIEQ
North Carolina Department of Environmental Quality
rL�n[O ��" UST Section, Mooresville Regional Office
LMW704.235.2182 (Office)
Trudy. B everlykncdenn gov
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
Office Mailing Address:
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Branch's Underground Storage Tanks Website Address: htips://deq.nc.gov/about/divisions/waste-manaaement/ust
Branch's Above Ground Storage Tanks Website Address: ht!ps:Hdeg.nc.gov/about/divisions/waste-management/ust/ast-proeram
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httns://deo.nc. eov/about/divisions/waste-management/waste-management-rules-data/waste-management-eis-mans
File Review Procedures:
https://deq.nc. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
hit 2s: //deg.nc. gov/about/divisions/waste-management/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
httys:Hfiles.nc.eov/nedeci/Waste%2OMana2ement/DWM/UST/WhatsNew/Final-Electronic-Document-Submittal-Policy.odf
htips:Hfiles.nc. gov/ncdeq/\Vaste%2OManagement/D WM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx
From: Ben Robinson[mailto:[e-mail]]
Sent: Monday, June 28, 20214:48 PM
To: Beverly, Trudy <[e-mail]>
Subject: [External] Atlantic American Property UST-61
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Please find attached to this e-mail the UST-61 for the Atlantic American Property located at 502 S. Main Street,
Kannapolis, NC 28081. Thank you very much!
Ben Robinson, L.G.
Paragon Environmental Consultants, Inc.