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HomeMy WebLinkAboutMO-28068_47338_UST-61_20201012_24-Hour Release and UST Leak Reporting FormUST-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 9/16/20 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: 407 S. Ridge Avenue county: Cabarrus Regional Office (circle one): Asheville, Mooresville Fayetteville, City/Town: Kannapolls Zip Code: 28083 Raleigh, Washington, Wilmington, Winston-Salem Latitude (decimal degrees): N 35.49070207' Longitude (decimal degrees) : W 80.626382230 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 9/11/20 (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 internally cleaned and filled in place week of 10/20/20 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 210 Oak Avenue City State Zip Code Telephone Number Kannapolis NC 28081 (704) 938-5400 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. 210 Oak Avenue City State Zip Code Telephone Number Kannapolis NC 28081 (704) 938-5400 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 10/12/20 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. M Environmental Laboratories Laboratory Certification #165 Client Name Paracon Environmental Consultants, Inc. Report Date 09/16/20 Project Name P-2083 Sample Matrix Soil Site Location 407 S. Ridge Ave. Analyst CWL Total Petroleum Hydrocarbons Meritech ID # Client Sample ID Analysis Performed Date Sampled Date Extracted Dilution Factor %Dry Solids Surrogate Recovery Results (m /k) Date Analyzed 09142005 T1-7 3660 09/11/20 09/14/20 N/A 750/. 410/. 154 09/16/20 Hydrocarbon Ranges Units of Measure DRO - 3550/8015C mg/kg GRO-5030/8015C mgfkg Reporting Limit for 3550 and 5030 = <10.0 mg/kg Was method blank below reporting limit? (YES) NO - Details Attached Spike Recovery Acceptance Range/Conc. Diesel 40 - 140% 300 ug/ml Gasoline 70 -130% 40 ug/ml Surrogate Recovery Acceptance Range/Conc. Chrysene 40 - 140% 100 ug/ml Bromochlorobenzene 70 - 130% 100 ug/ml 5030 LCS/LCSD RPD = N/A 5030 MS/MSD RPD = N/A RPD Limit = 15 Sample Weight: DRO=30.Og GRO=10.Og TPH Surrogates/Spikes DRO13550: Chrysene/Diesel GRO/5030 Bromochlorobenzene/Gasoline 5030 Lab Spike Recovery = N/A 5030 Lab Spike Duplicate Recovery = N/A 5030 Matrix Spike Recovery = N/A 5030 Matrix Spike Duplicate Recovery = N/A 3550 Lab Spike Recovery = 99 % 3550 Lab Spike Duplicate Recovery = 114% 3550 Matrix Spike Recovery = 108 % 3550 Matrix Spike Duplicate Recovery = N/A 3550 LCS/LCSD RPD = 14.1 3550 MS/MSD RPD = N/A " Surrogate/Spike/RPD exceeds limits. * Surrogate/Spike diluted out/matrix interference. fPH Report Revision 05/05/09 I hereby certify that I have reviewed and approve these data. / a9,a Chain of Custody Record (COC) NPDES#: Client: „ Phone: Address �.�_�.� lr �:� i���i„�i��-pr.i,r�,::im„.1,,,�,. Fax: (sl(ill E C 7361 Email: Project: y/°S• /� i �y e Ave, i' Attention: f3✓ar7da,7 Moor2 Turn around Time* *RUSH work needs prior approval, How would you like your report sent? Char es A Circle all that app y: ( I all St d 10da s) 3-s Days 24�4sltrs pre err ), Fax, Mail x I MERITECH, INC. ENVIRONMENTAL LABORATORIES i 642 Tamco Rd. Phone: 336-342-4748 Reidsville NC 27320 Fax: 336-342-1522 Email: info@meritechlabs.com www.meritechlabs.com Sample Location and/or ID # Sampling Dates & Times Person Taking Sam ign/Print): / Lab use Only Start I End Comp? Grab? #of Cont, Test(s) Required No Yes es /N pH ? Cl OK? Date Time Date Time io,vik 9/ e %' CT/-?) 91� 7.yo C� �/A Nle,yao( 355� d5 I 1-7 Temperature Upon Receipt: Method of *** Dechlorination (<0.5 p m) of Ammonia, Cyanide, Ph of -tKN m ii must. Ftone in the field prior to preservation. *** l Shipment: Comments: 1''^-'% e7 Compositor# ❑ ups Jug # ❑ Fed Ex Are these results for regulatory purposes? Yes No ❑ Report In: mg/L ❑ mg/kg 19 ug/L ❑ ® Hand Delivery Relinquished by: Date / Time: / �vl 9 v Receiv d b : Date: Time: �J O ❑ Other Reli uis ed y: Dat . Ti e J 1 Rec ,ve y: oat . Time: Reli uished by: Da e: Time: ved by , Time 0 o gle Maps 407 S Ridge Ave Atlantic American Property m Distribuidores Yrxsr yyF SY La Reina De Las Virginia's Dress Shop o hest Women's clothing store Bp G4 North Carolina Music Hall Of Fame U g Gannon Village Q ed m Shopping mall v m Carolinas Sports 0 �4y Entertainment TV 61 �C'St h N R 9Ada msAutc �407 South Ridge Avenue Kannapolis Bitcoin f 0'0 yyG ATM - Bitstop � a Vell's-Saul Food ¢ sr A Twist with Marable Memorial Auto Tech �G Takeout- Delivery AMEZion y+m Caharrus Cc Limy EMS Station 4 4 �d~qF EXXON #7 Rx sae Stroup Supply ¢sue {to ( T � sr G&S0S Auto partsstore Farrington Family Fifth Third Bank & ATM Medical Center New Piney Grove �a Baptist Church ��++rle We Veterans & �diciy «7 United States 9 Gift shop so Postal Service _ Earn }tar 11 Map data ©2020 200 ft Beverly, Trudy From: Beverly, Trudy Sent: Monday, October 12, 2020 3:02 PM To: Ben Robinson Subject: RE: [External] Atlantic American Property UST-61 Received. 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:brobinson8915@gmail.com] Sent: Monday, October 12, 2020 2:43 PM To: Beverly, Trudy <trudy.beverly@ncdenr.gov> Subject: [External] Atlantic American Property UST-61 External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to report.spam@nc.gov Hello Trudy, please find attached to this e-mail the UST-61 for the Atlantic American Property, located at 407 S. Ridge Avenue, Kannapolis, NC 28083. Thank you very much! Ben Robinson, L.G. Paragon Environmental Consultants, Inc.