MO-28244_47502_CA_UST-61_20210112_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 12/23/20
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: Allcea Property
Address: 1951 Sequoia Hills Drive
County: Cabarrus
Regional Office (circle one): Asheville, Mooresville Fayetteville,
City/Town: Harrisburg
Zip Code: 28075
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): N 35.31407000' Longitude (decimal degrees) : W 80.608193390
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 12/15/20 (TPH results attached)
-Only supply well within 150 feet of source area scheduled to be abandoned
-Notice of Residual Petroleum signed by RP to be submitted
-UST to be removed with next couple 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
0. 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
Luz C. Alicea
Point of Contact
Address
1951 Sequoia Hills Drive
City
State
Zip Code
Telephone Number
Harrisburg
NC
28075
N/A
UST SYSTEM OPERATOR
UST Operator/Company
Address
Unknown
City
State
Zip Code
Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
Address
Luz C. Alicea
1951 Sequoia Hills Drive
City
State
Zip Code
Telephone Number
Harrisburg
NC
28075
N/A
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 1/12/21
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 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

Case Narrative
Waypoint.
ANALYTICAL
Paragon Environmental Consultants, Inc.
Brandon Moore
PO Box 157
Thomasville, NC 27361
NC Certification No. 402
NC Drinking Water Cert No. 37735
SC Certification No. 99012
Project: 1951 Sequoia Hills Dr.
Lab Submittal Date: 12/16/2020
Work Order: 0120267
12/23/20 9:51
This data package contains the analytical results for the project identified above and includes a Case Narrative, Sample
Results and Chain of Custody. Unless otherwise noted, all samples were received in acceptable condition and processed
according to the referenced methods.
Data qualifiers are flagged individually on each sample. A key reference for the data qualifiers appears at the end of this case
narrative.
Please call if you have any questions relating to this analytical report.
Respectfully,
WAYPOINT ANALYTICAL
a,j
Angela D. Overcash
Senior Project Manager
Data Qualifiers Key Reference:
DO Surrogates diluted out.
BRL Below Reporting Limit
MDL Method Detection Limit
RPD Relative Percent Difference
* Results reported to the reporting limit. All other results are reported to the MDL with values between MDL and
reporting limit indicated with a J.
This report should not be reproduced, except in its entirety, without the written consent of Waypoint Analytical.
449 Springbrook Road - P.O. Box 240543 - Charlotte, NC 28224-0543
Phone: [phone] - Toll Free Number: 1-800/529-6364 - Fax: [phone] Page 1 Of 6

0
Waypoint.
ANALYTICAL
Sample Receipt Summary
12/23/2020
Work Order: 0120267
Client Sample ID Lab Sample ID Matrix Date/Time Sampled Date/Time Received
TI-5
0120267-01 Solid 12/15/20 15:40 12/16/20 15:10
Samples were received in good condition at 0.5 degrees C unless otherwise noted.
This report should not be reproduced, except in its entirety, without the written consent of Waypoint Analytical.
449 Springbrook Road - P.O. Box 240543 - Charlotte, NC 28224-0543
Phone: [phone] - Toll Free Number: 1-800/529-6364 - Fax: [phone] Page 2 0f 6

Way poi nt .
ANALYTICAL
Waypoint ID Client ID
0120267-01 TI-5
Parameter
Diesel Range Organics
Summary of Detections
12/23/2020
Work Order: 0120267
Method Result
*8015C 8700
Units
mg/kg dry
This report should not be reproduced, except in its entirety, without the written consent of Waypoint Analytical.
449 Springbrook Road - P.O. Box 240543 - Charlotte, NC 28224-0543
Phone: [phone] - Toll Free Number: 1-800/529-6364 - Fax: [phone] Page 3 0f 6

Laboratory Report
• � 12/23/2020
PA Waynt.�
ANALYTICAL
Paragon Environmental Consultants, Inc. Project: 1951 Sequoia Hills Dr. Client Sample ID: TI-5
Attn: Brandon Moore Sample ID: 0120267-01
PO Box 157 Work Order: 0120267
Thomasville, NC 27361 Sample Matrix: Solid Time Collected: 12/15/20 15:40
Time Submitted: 12/16/20 15:10
Parameter Result Units Report MDL Dilution Method Analysis Analyst Batch
Limit Factor Date/Time ID
Diesel Range Organics by GC/FID
Diesel Range Organics 8700 mg/kg dry 460 150 50 *8015C 12/18/20 17:35 ZRC POL0378
Surrogate Recovery Control Limits
o-Terphenyl 0 % 31-123 DO
General Chemistry Parameters
% Solids 76.2 % by 0.100 0.100 1 *SM2540 G 12/21/20 14:21 SMW POL0435
Weight
This report should not be reproduced, except in its entirety, without the written consent of Waypoint Analytical.
449 Springbrook Road - P.O. Box 240543 - Charlotte, INC 28224-0543
Phone: [phone] - Toll Free Number: 1-800/529-6364 - Fax: [phone] Page 4 0f 6

® Level II QC Report
Waynt
� 12/23/20
poi
ANALYTICAL
Paragon Environmental Consultants, Inc. Project: 1951 Sequoia Hills Dr. Work Order: 0120267
Attn: Brandon Moore Time Submitted: 12/16/2020 3:10:OOPM
PO Box 157
Thomasville, NC 27361
Diesel Range Organics by GC/FID - Quality Control
Reporting Spike Source %REC RPD
Analyte Result Limit Units Level Result %REC Limits RPD Limit Notes
Batch POL0378 - 3546
Blank (POL0378-BLK1)
Prepared & Analyzed: 12/18/20
Diesel Range Organics
BRL
7.0 mg/kg wet
Surrogate: o-Terphenyl
1.15
mg/kg wet
1.342 86
31-123
LCS (POL0378-BS1)
Prepared &Analyzed: 12/18/20
Diesel Range Organics
55.8
7.0 mg/kg wet
67.05 83
46-126
Surrogate: o-Terphenyl
1.17
mg/kg wet
1.341 87
31-123
LCS Dup (POL0378-BSD1)
Prepared &Analyzed: 12/18/20
Diesel Range Organics
57.0
7.0 mg/kg wet
66.69 85
46-126 2 20
Surrogate: o-Terphenyl
1.21
mg/kg wet
1.334 91
31-123
Sample Extraction Data
Prep Method: 3546
Lab Number Batch Initial Final Date/Time
0120267-01 POL0378 30.06 g 1 mL 12/18/20 8:20
Prep Method: Solids, Dry Weight
Lab Number Batch Initial Final Date/Time
0120267-01 POL0435 30 g 30 g 12/21/20 14:21
This report should not be reproduced, except in its entirety, without the written consent of Waypoint Analytical.
449 Springbrook Road - P.O. Box 240543 - Charlotte, NC 28224-0543
Phone: [phone] - Toll Free Number: 1-800/529-6364 - Fax: [phone]
Page 5of6

Waypointo
ANALYTICAL
449 Springbrook Road • Charlotte, NC 21217
Phone [phone] • Fax: [phone]
Client Company Name:+
Report To/Contact Nam AAU r
Reporting Address: P.e Box 147
c!� r
CHAIN OF CUSTODY RECORD
PAGE _ OF _ ,QUOTE # TOENSURE PROPER BILLING:
Project Name:
Short Hold Analysis (Yes) No) UST Project: • es) (NO) .
*Please ATTACH any project sftecffic reporting (QC LEVE I IV)
provisions ar/or QC Requirements
Invoice To: Tdionpri
Address:
YES NO N/A
Samples INTACT upon arrival?
Received ON WET ICE?
PROPER PRESERVATIVES indicated?
Received WITHIN HOLDING TIMES?
CUSTODY SEALS INTACT?
VOLATILES rec'd W/OUT HEADSPACE?
PROPER CONTAINERS used?
• ��� _
TEMP: Therm l.D: R'T' j Observedy C lCorr.�-°C
Phone: Fax (Yes)(No): Purchase Order No./Billing Reference
Email Address: QMe0/ Ylo S L Requested Due Date ❑ 1 Day ❑ 2 Days ❑ 3 Days ❑ 4 Days N�5 Days
EDD Type: PDFIX _ xcelOther "Working Days" ❑ 6-9 Days ❑ Standard 10 days ❑ Rush Work Must Be
Pre Approved,
Site Location Name: ok 1 rldlg. Samples received after 14:00 will be processed next business day.
Site Location Physical Addres SI U 1 , (f DfW Turnaround time is based on business days, excluding weekends and holidays.
drrts yr NC 2�075 (SEE REVERSE FOR TERMS & CONDITIONS REGARDING SERVICES
RENDERED BY WAYPOINT ANALYTICAL, LLC TO CLIENT)
TO BE FILLED IN BY CLIENT/SAMPLING PERSONNEL
Certification: NELAC FL NC_X
SC OTHER NIA
Water Chlorinated: YES_ NO
Sample Iced Upon Collection: YES K No
TIME
MATRIX
SAMPLE CONTAINER
ANALYSIS REQUESTED
CLIENT
SAMPLE DESCRIPTION
DATE
COLLECTED
COLLECTED
MILITARY
HOURS
(SOIL,
WATER, OR
SLUDGE)
PRESERVA-
TIVES
REMARKS
ID NO.
*TYPE
SEE BELOW
NO.
SIZE
ToAk#l@S
Soi
I
x
• • .
PRESS FIRMLY - 2
IES
Sampler's Signatur _ 1 Sampled By (Print Name) %crivil", L/ 0064104 Affiliation DOWN
U n relinquishing, Chain of Custody is your authorization for Waypoint Analytical to proceed with the analyses as requested above. Any changes must be
S m' itted in writing to the Waypoint Analytical Project Manager. There will be charges for any changes after analyses have been initialized. LAB USE ONLY
nquished By:,Jy;lgnature) I , Received By: (Signature) Date Military/Hours Additional Comments: Site Arrival Time:
/ I� �� (,I Z.5
in wished By: (Signature) FMceived y: (Signature) to Site Departure Time:
Relinquished By: (Signature) Received For Waypoint Analytical By: Date Field Tech Fee:
) Z � ,? /s/d Mileage:
Method or Shipment: NOTE: ALL SAMPLE COOLERS SHOULD BE TAPED SHUT WITH CUSTODY SEALS FOR TRANSP RTATION TO THE ORATORY. C Group No. ///���
SAMPLES ARE NOT ACCEPTED AND VERIFIED AGAINST CDC UNTIL RECEIVED AT THE LABO TORY. .
❑ Fed Ex ❑ UPS 9Hand-delivered OW aypoint Analytical Field Service ❑ Other /
NPDES: UST, TER: ING SOLID
GROWATER: FLD IL240THER: — SEE REVERSE FOR
F❑
SC I ❑O NC ❑ SC TERMS & CONDITIONS
❑ NC ❑ SC � NC ❑ SC ❑ INCU ❑ SC ❑ NICK ❑ SC NC ❑ SCTE ❑❑ NC ❑ SC ❑❑ NCN ❑ SC ❑❑ NC
I
❑ ❑ ❑ ❑
*CONTAINER TYPE CODES: Ate= Amber C = Clear G= Glass P = Plastic; TL = Teflon -Lined Cap VOA = Volatile Organics Analysis (Zero Head Space) Page 6 of 6

o gle Maps 1951 Sequoia Hills Dr
Back CrL-ek
r
„q
1951 Sequoia Hills Dr, a
Harrisburg, INC 28075
�A
7'
4'
� r
RR r
CreeV, Paul Linker Rd
Pau! Linker Rd
A�
ogle
Map data ©2021 200 ft r r

Beverly, Trudy
From: Beverly, Trudy
Sent: Tuesday, January 12, 2021 8:57 AM
To: Ben Robinson
Subject: RE: [External] Alicea Property UST-61
Received.
Trudy
Trudy Beverly, L.G.
D
IE �1
Hydrogeologist, Division of Waste Management
_ North Carolina Department of Environmental Quality
Q�
LF Pa.rI n. of Lnorun,w 0MOT ` UST Section, Mooresville Regional Office
704.235.2182 (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: ht_pt s://deg.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: hgps:Hdeg.nc.gov/about/divisions/waste-management/ust/ast-proeram
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httns://deu.nc. eov/about/divisions/waste-manaeement/waste-manaeement-rules-data/waste-manaeement-eis-mans
File Review Procedures:
ht_pt s://deq.nc.gov/about/divisions/waste-manaeement/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
httns: //dea.nc. eov/about/divisions/waste-manaeement/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
httys:Hfiles.nc.eov/nedea/Waste%2OMana2ement/DWM/UST[WhatsNew/Final-Electronic-Document-Submittal-Policy.odf
https:Hfiles.nc.gov/ncdeg/Waste%2OManagement/D WM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx
From: Ben Robinson [mailto:[e-mail]]
Sent: Tuesday, January 12, 2021 8:28 AM
To: Beverly, Trudy <[e-mail]>
Subject: [External] Alicea 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 Alicea Property. Thank you very much!
Ben Robinson, L.G.
Paragon Environmental Consultants, Inc.