MO-29984_49069_CA_SCH_20230504

2725 E. Millbrook Road, Suite 121
Raleigh, North Carolina 27604
Telephone [phone]
Fax [phone]
www.oneatlas.com

May 4, 2023

Mr. Ron Taraban
North Carolina Department of Environmental Quality
Mooresville Regional Office
Division of Waste Management – UST Section
810 East Center Avenue, Suite 301
Mooresville, North Carolina 28115

Re: Site Check Report – Tank #3 Auto Diesel STP Sump
Pilot Store #7971
1343 Rock Barn Road
Conover, Catawba County, North Carolina
NCDEQ Facility ID #00-0-0000034426

Dear Mr. Tarban:

ATC Associates of North Carolina, LLC (ATC), on behalf of Pilot Travel Centers, LLC, is submitting this Site
Check Report for the referenced facility.

If you have any questions or require additional information, please contact our office at [phone].

Sincerely,
ATC Associates of North Carolina, LLC

Maureen Jackson, P.G. Sam Wakefield
Senior Project Manager Program Manager

cc: Mr. Joey Cupp, Pilot Travel Centers, LLC

SITE CHECK REPORT – TANK #3 AUTO DIESEL STP SUMP

PILOT STORE #7971
1343 Rock Barn Road
Conover, Catawba County, North Carolina
NCDEQ Facility ID #00-0-0000034426

Pilot Store #7971 May 4,2023
NCDEQ Facility ID #00-0-0000034426 Site Check Report
Site Check Report
A. Site InformationL Site Identification
Date of Report: 0510412023
Facility ID #: 00-0-0000034426 UST lncident # Not Assigned
Site Name: Pilot Store #7971
Site Street Address: 1314 Rock Barn Road
City/Town: Conover Zip Code:28613 County: Catawba
Description of Geographical Data Point: Auto Diesel UST Basin
Location Method: Goosle Earth
Latitude: 35.720543" N Longitude 8 l. I 88653" W
Information About Contacts
UST Owner and Operator: Pilot Travel Centers. LLC
Address: 5508 Lonas Road Knoxville. Tennessee 37909 Tel: [phone] I 06
Property Owner:PFJ Southeast LLC c/o Intax- Inc.
Address: P.O. Box 54650 Lexington. Kentucky 40555
Property Occupant: Pilot Store #7971
Address: 1343 Rock Bam Road Conover. North Caorlina 28613
Consultant/Contractor: ATC Associates of North Carolina. P.C.
Address: 609,{ Piner Road. Suite I l5 Wilmington. North Carolina 28409Te1: 919-871-0999
Analytical Laboratory: Pace Analytical Cert #: 315
Address: I 540 Lovell Road Knoxville. Tennessee 3793 I Tel: [phone]
3. Information About Release
Date Discovered: Not Applicable
Estimated Quantity of Release: Unknown
Cause of Release: Unknown
Source of Release: Tank #3 Auto Diesel STP Sump Failed Hydrostatic Test
Size and Contents of UST System: See Table 2
I, Maureen A. Jackson. a Li
information contained in th
(Please Affix Seal and Si
North Carolina. The certifi
Associates of North Carolina, P.C. do certify that the
ruate to the best of my knowledge.
practice geology/engineering (circle one or both)ln
L) or corporation is e l:598,v n.
ATC Associates of North Carolina
Complete and include in report items B through H in the order listed.
Pilot Store #7971 May 4, 2023
NCDEQ Facility ID #00-0-0000034426 Site Check Report

ATC Associates of North Carolina
B. Site History

1. Provide UST Owner and Operator Information

See Table 1.

2. Provide UST Information

See Table 2.

3. Provide Non-UST Information

No ASTs or Surface Spills are known to exist at the site.

4. Describe relation of location of current UST system to historical UST releases.

A previous release, UST incident #36396, was discovered on September 20, 2007, when
gasoline was observed leaking from an unleaded gasoline line within a containment sump
during a routine compliance inspection conducted by the North Carolina Department of
Environmental Quality (NCDEQ).

During January 2010, light non-aqueous phase liquid (LNAPL)(diesel fuel) was detected in
monitoring well MW-3, which is located near the truck diesel fuel dispensers.

On July 6, 2020, a release of diesel fuel from dispenser #18 was reported to the NCDEQ.
LNAPL was present in the under-dispenser containment (UDC) and it was determined that the
source of the fuel was a leaking meter. The NCDEQ has determined that this release is
considered commingled with the existing UST incident #36396.

5. Provide a Brief Description of Site Characteristics

The subject property consists of one convenience store building and petroleum fueling
equipment (a truck stop). The subject property and surrounding area are fairly level. The
subject property is located in a light commercial area in proximity to Interstate-40. Public
water is supplied to the subject facility. A topographic map and site map are attached as
Figures 1 and 2, respectively.

C. Site Check Procedures

1. UST System Testing
On March 13, 2023, Pilot contracted with SPATCO to repair a leaking flex line within the tank
#3 auto diesel submersible turbine pump (STP) containment sump. Documentation of the flex
line repair is provided in Attachment I. On March 14, 2023, SPATCO returned to the site to
hydrostatically test the tank #3 auto diesel STP containment sump. The STP containment sump
was found to not pass its hydrostatic test on this date. A copy of the UST-6F/23B Triennial
UST Containment Sump/UDC Integrity Testing is provided in Attachment I.

Pilot Store #7971 May 4, 2023
NCDEQ Facility ID #00-0-0000034426 Site Check Report

ATC Associates of North Carolina
On March 17, 2023, ATC personnel, on behalf of Pilot Travel Centers, submitted a UST-17A
UST Suspected Release 24 Hour Notice. Copies of the referenced notifications are provided in
Attachment I.

2. Site Check Procedure
On April 13, 2023, ATC personnel contracted with AmeriProbe of Huntersville, North Carolina
to advance a soil boring as close as possible to the tank #3 auto diesel STP sump. The soil
boring was advanced to thirteen feet below ground surface (bgs). A soil sample was collected
from the boring at an approximate depth of thirteen feet bgs. The soil sample was labeled
SB-1(13’). The location of the soil boring is provided on Figure 2. The boring log is provided
in Attachment II.

It should be noted the soil boring was advanced as close as possible to the tank #3 auto diesel
STP sump.

3. Soil Excavation Activities
Soil excavation was not performed as part of this site check.

D. Site Investigation

1. Field Screening
The soil boring was screened with a photoionization detector (PID) at two-foot intervals to
boring termination depth. The respective PID readings are provided on the boring log in
Attachment II.

2. Soil Sampling Information
The soil sample, collected from the borehole, was noted to be a brown silt with micra. The soil
sample was noted to be dry.

The soil sample was shipped to a N.C. certified laboratory in a chilled cooler following proper
chain-of-custody procedures. The soil sample was requested to be analyzed by TPH-Gasoline
Range Organics (GRO) and TPH-Diesel Range Organics (DRO).

3. Groundwater and Surface Sampling Information
Groundwater and surface water samples were not collected during site check activities.

4. Quality Control Measures
The soil sample was placed in laboratory provided jars and vials. The sample was immediately
placed on ice and contained in a cooler during transportation. The sample was transported by
courier under a chain-of-custody to the laboratory for analysis.

5. Investigation Results
Laboratory analytical results of the soil sample collected in proximity to the tank #3 auto diesel
STP sump did not detect TPH-GRO or TPH-DRO concentrations above the established State
Action Levels. The laboratory analytical results are provided on Table 3. A copy of the
laboratory report and chain-of-custody documents are provided in Attachment III.

Pilot Store #7971 May 4, 2023
NCDEQ Facility ID #00-0-0000034426 Site Check Report

ATC Associates of North Carolina
E. Conclusion and Recommendations
Laboratory analytical results of the soil sample collected in proximity to the tank #3 auto diesel
STP sump did not detect TPH-GRO or TPH-DRO concentrations above the established State
Action Levels. Based on the soil analytical data, it appears a release of petroleum has not
occurred from the tank #3 auto diesel STP sump.

F. Figures
Figure 1 – Topographic Map
Figure 2 – Site Map with Boring Location

G. Tables
Table 1 – UST Owner and Operator Information
Table 2 – UST/AST System Information
Table 3 – Soil Analytical Results

H. Attachments
I – Notifications and Testing Results
II – Boring Log
III –Laboratory Reports and Chains-of-Custody Documents

TABLES
TABLE 1
UST OWNER AND OPERATOR INFORMATION
PILOT STORE #7971
1343 ROCK BARN ROAD
CONOVER, CATAWBA COUNTY, NORTH CAROLINA
NCDEQ FACILITY ID #00-0-0000034426
Revision Date:4/25/2023 Incident Number and Name:Pilot Store #7971
UST ID Number All Facility ID Number 00-0-0000034426
City State Zip Telephone Number
Knoxville TN 37909 865-474-3106
City State Zip Telephone Number
Dates of Operation (MM/DD/YY to MM/DD/YY)Name of Owner
Dates of Operation (MM/DD/YY to MM/DD/YY)Name of Operator
5508 Lonas Road
Pilot Travel Centers, LLC 8/22/1995 to Present
Street Address
As Above
Street Address
TABLE 2
UST/AST SYSTEM INFORMATION
PILOT STORE #7971
1343 ROCK BARN ROAD
CONOVER, CATAWBA COUNTY, NORTH CAROLINA
NCDEQ FACILITY ID #00-0-0000034426
Revision Date:4/25/2023
UST ID Number
Current/Last
Contents
Previous
Contents
Capacity
(gallons)
Construction
Details
Tank
Dimensions
Description of
Associated
Piping and
Pumps
Date Tank
Installed
Date
Piping
Installed Status of UST
Was Release
Associates with
the UST System?
1 Gasoline None 10,000 DW Steel/FRP Unknown SW FRP 08/22/95 10/14/07 Active No
2 Gasoline None 12,000 DW Steel/FRP Unknown SW FRP 08/22/95 10/14/07 Active No
3 Diesel None 20,000 DW Steel/FRP Unknown SW FRP 08/22/95 10/14/07 Active No
4 Diesel None 20,000 DW Steel/FRP Unknown SW FRP 08/22/95 10/14/07 Active No
AST ID Number
Current/Last
Contents
Previous
Contents
Capacity
(gallons)
Construction
Details
Tank
Dimensions
Description of
Associated
Piping and
Pumps
Date Tank
Installed Status of AST
Was Release
Associates with
the AST System?
Incident Number and Name:Pilot Store #7971
None associated with this site
TABLE 3
SOIL ANALYTICAL RESULTS
PILOT STORE #7971
1343 ROCK BARN ROAD
CONOVER, CATAWBA COUNTY, NORTH CAROLINA
NCDEQ FACILITY ID #00-0-0000034426
SB-1(13')13
near Tank #3
diesel STP
sump
0.0 4/13/2023 <1.11 1.22J
50 100
Notes:
1. Concentrations reported in milligrams per kilogram (mg/kg).
2. PID denotes photoionization detector.
3. PPM denotes parts per million.
4. TPH denotes total petroleum hydrocarbons.
5. GRO denotes gasoline range organics.
6. DRO denotes diesel range organics.
7. J denotes concentration estimated by project laboratory.
State Action Level (mg/kg)
Analytical Method EPA METHOD 8015
Sample
Depth
(feet)
Sampling
Location
PID
Reading
(ppm)
Date
Sampled TPH-GROTPH-DRO

FIGURES
PILOT #7971INTERSTATE 40 OFFRAMPROCK BARN
ROADSB-1

ATTACHMENT I
UST.I7A UST Suspected Release 24 Hour Notice
Do not use this form to report a 24 hour notice of a Pollution lncident. You must use form UST-61, 24 Hour Release and :JST LeakReporling Form.
! This form must be used to report to DEQ, within 24 hours of discovery, a Suspected Release from any of the following:a) Failed or inconclusive leak detection or tightness test results. This includes positive test results, such as "lncrease", whichindicates the level in the UST system has increased more than 0.2 gph.b) Unusual operating conditions which can include, but are not limited to: the erratic behavior of dispensing equipment; theunexplained presence of water in the tank; the presence of fuel in containment sumps or interstitial spa""s; oi tne degradation ofany equipment or e_lement of an underground storage tank system to the point where that equipment or element can iot reasonablybe expected to perform its intended function.
c) lnternal inspection results such as, perforations, corrosion holes, weld failures, or other similar defects that indicate a releasecould have occurred.
> lf you have more than four UST systems to report suspected releases, then attach additional sheets of the UST-174 form. you onlyneed to list the UST systems at your site that have suspected releases.> Within 7 days of discovery, submit a UST-178 form to documentthe response activities taken to investigate the suspected release.! Please submit ttiis form to: NCDEe/DWM, UST Section
1646 Mail Service Center
Raleigh, North Carolina 27699-1646
II. UST FACILITY
Name:
Pilot Travel Centers
Address:
5508 Lonas Drive Addressl
1343 Rock Barn Road
Sr. PM ATC on behalf of Pilot
Telephone Number:
(9191 561-3893 March 17,2023
Location and/or source of
suspected release:
(check all that apply)
! ranr
fl eiping
I TankSump
I Dispenser Sump .
E Spi[ Bucket
! lnternal lnspection
f] otner (Exptain in
comments).
I ranr
I etping
f] rank Sump
! Dispenser sump
E Spi[ Bucker
! lnternal tnspection
E Omer (Exptain in
comments)
! rant
! eipins
! TankSump
! Dispenser Sump
E Spiil Bucker
! lntemal lnspection
E Otne, (Explain in
comments)
! rant
! eiping
! TankSump
! Dispenser Sump
E Spiil Bucket
I tntemal lnspection
E Otn", (Explain in
comments)
Leak detection method or
other observation that
indicates a suspected
release. (e.9., ATG, SlR,
visual contamination, fuel
in sump, etc.):
Flex product line repair in
STP. STP failed its
hydrostatic test
Failed/l nconclusive date or
date that leak detection
method suspected release
discovered:
Test results attached. Site check being initiated
UST-174 Revised 10t2018 http ://wv\M.wastenotnc. org/
OR
Fax to [phone] OR UST. Permits@ncden r qov
I. UST OWNER
Name: I Facility tD:Pitot797t I oo_o_ooooo34426
L;rly: lState: lzo:Knoxvitte lrru I gzsos uny: I County:Conover I CatawbaHerson Hepontng:
Maureen Jackson, PG
III. UST INFORMATION
Tank Number i Size:3 I Unknown
Product Stored:Auto Diesel
\Aarch 1 4, 2023
IV. COMMENTS
UST-6F/23B Triennial UST Containment Sump / UDC Integrity Testing
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION 1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE [phone] FAX [phone] http://www.wastenotnc.org/5/2020
Page 1 (Full height hydrostatic or vacuum test)
· If any periodic test fails, a suspected release report must be submitted on a UST-17A form, UST Suspected Release 24 Hour Notice. The suspected
release must be investigated, in accordance with 15A NCAC 2N .0603, and defective equipment repaired or replaced in accordance with 15A NCAC 2N .0404/.0900. Results of the investigation must be submitted on a UST-17B form, UST Suspected Release 7 Day Notice.
· Containment sumps installed on or after 11/1/2007 that are not monitored continuously for releases using vacuum, pressure, or hydrostatic interstitial
monitoring methods and all other containment sumps installed prior to 11/1/2007 that are used for interstitial monitoring shall be tightness tested at installation and every three (3) years thereafter in accordance with the manufacturer's written guidelines, PEI/RP100 “Recommended Practices for Installation of Underground Liquid Storage Systems” and/or PEI/RP1200 “Recommended Practices for the Testing and Verification of Spill, Overfill, Leak Detection and Secondary Containment Equipment at UST Facilities.”
· If a UDC / containment sump fails a periodic tightness test, the sump must be replaced or repaired by the manufacturer, or the manufacturer's
authorized representative in accordance with the manufacturer's specifications.
UST FACILITY
Owner / Operator Name Facility IDFacility Name
Facility Street Address Facility City County
CONTRACTOR/PERSON CONDUCTING INSPECTIONS
Company Name Phone Email address
I certify, under penalty of law, that the testing data provided on this form documents the UST system equipment was checked in accordance with the manufacturer's guidelines and the applicable national industry standards listed in 15A NCAC 2N .406 and/or 15A NCAC 2N .0900.
Print Name of person conducting test Signature of person conducting test Test Date
Identify UDC/sump (By Dispenser No. or Tank Number,
Tank Size, Stored Product; e.g. #1 10k Regular STP, Disp 1/2,
etc.)#:
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
Transition sumps should be listed above as “TS-XX” (with XX= sump ID#)
Sump Material FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
Sump Type Single Wall
Double Wall
Single Wall
Double Wall
Single Wall
Double Wall
Single Wall
Double Wall
Single Wall
Double Wall
Single Wall
Double Wall
Test Type Hydrostatic
Vacuum
Hydrostatic
Vacuum
Hydrostatic
Vacuum
Hydrostatic
Vacuum
Hydrostatic
Vacuum
Hydrostatic
Vacuum
Indicate units for all measurements
Liquid and debris removed from sump?Yes No Yes No Yes No Yes No Yes No Yes No
Visual inspection (No cracks, loose parts or separation of the
containment sump)
Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Sump Depth
Height from sump bottom to top of highest penetration or sump
sidewall seam
Wait time between applying
vacuum/water and start of test
Begin ị End Test Time (minimum test time: 1 hour)
Begin ị End values
Pass/Fail criteria: Must pass visual inspection. Hydrostatic: Water level drop of 1/8 inch or more fails the test, Water level must be 4 or more inches above highest penetration or side wall seam or test is invalid; Vacuum: No change in vacuum
Test Results Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Comments: (include information on repairs made prior to testing, and recommended follow-up for failed tests)
Date next Containment Sump/UDC integrity test due (required every 3 years)
Pilot Travel Centers 00-0-0000034426Pilot 7971
1343 Rock Barn Road Conover Catawba
Joseph Nitschke 1800-4SPATCO [e-mail]
Joseph Nitschke 03/14/2023
3 Auto Diesel
36”
18”
20 minutes
13:47 14:47
24”11”
UST-6F/23B Triennial UST Containment Sump / UDC Integrity Testing
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION 1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE [phone] FAX [phone] http://www.wastenotnc.org/5/2020
(Low Liquid Level Test)Page 2
· Containment sumps installed on or after 11/1/2007 that are not monitored continuously for releases using vacuum, pressure, or hydrostatic interstitial monitoring methods and all other containment sumps installed prior to 11/1/2007 that are used for interstitial monitoring can be tightness tested every
three (3) years in accordance with the NCDEQ Low Level Hydrostatic Integrity Test Procedures which can be found on the UST section website at https://deq.nc.gov/about/divisions/waste-management/ust/forms. This method cannot be used for the installation testing of containment sumps.
· If any periodic test fails, a suspected release report must be submitted on a UST-17A form, UST Suspected Release 24 Hour Notice. The suspected release must be investigated, in accordance with 15A NCAC 2N .0603, and defective equipment repaired or replaced in accordance with 15A NCAC 2N .0404/.0900. Results of the investigation must be submitted on a UST-17B form, UST Suspected Release 7 Day Notice.
· If a UDC / containment sump fails a periodic tightness test, the sump must be replaced or repaired by the manufacturer, or the manufacturer's authorized representative in accordance with the manufacturer's specifications.
· Attach all setup reports (e.g. Veeder-Root: Output Relay Setup, Incon: Main console setup) for the sensor alarms positive shut-down to this form. If the
dispenser has a standalone sensor to shut-down the dispenser then annotate on the test form in the comments section.
UST FACILITY
Owner / Operator Name Facility IDFacility Name
Facility Street Address Facility City County
CONTRACTOR/PERSON CONDUCTING INSPECTIONS
Company Name Phone Email address
I certify, under penalty of law, that the testing data provided on this form documents the UST system equipment was checked in accordance with the
manufacturer's guidelines and the applicable national industry standards listed in 15A NCAC 2N .406 and/or 15A NCAC 2N .0900, or another method approved by NC DEQ.
Print Name of person conducting test Signature of person conducting test Test Date
Identify UDC/sump (By
Dispenser No. or Tank Number,
Tank Size, Stored Product; e.g. #1 10k Regular STP, Disp 1/2,
etc.)#:
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
Transition sumps should be listed above as “TS-XX” (with XX= sump ID#)
Sump Material FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
Indicate units for all measurements
Liquid and debris removed from sump?Yes No Yes No Yes No Yes No Yes No Yes No
Is sensor 2” or less from lowest portion of sump bottom?Yes No Yes No Yes No Yes No Yes No Yes No
Visual inspection (No cracks, loose parts or separation of the
containment sump)
Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Did sensor alarm when tested?Yes No Yes No Yes No Yes No Yes No Yes No
If sensor alarms, did the STP and/or dispenser shut-off? Note for dispenser sensors all product types in the dispenser must be disabled.
Yes No Yes No Yes No Yes No Yes No Yes No
Level above bottom of sump where sensor alarms (inches)
Wait time between applying water and start of test
Begin ị End Test Time (minimum test time: 1 hour)
Begin ị End values
Pass/Fail criteria: Any No or Fail in the above, the sump fails the test . Hydrostatic: Water level drop of 1/8 inch or more fails the test.
Test Results Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Comments: (include information on repairs made prior to testing, and recommended follow-up for failed tests)
Date next Containment Sump/UDC integrity test due (required every 3 years)
Pilot Travel Centers 00-0-0000034426Pilot 7971
1343 Rock Barn Road Conover Catawba
Joseph Nitschke 1800-4SPATCO [e-mail]
Joseph Nitschke 03/14/2023
UST-6F/23B Triennial UST Containment Sump / UDC Integrity Testing
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION 1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE [phone] FAX [phone] http://www.wastenotnc.org/5/2020
(Dri-Sump® Test)Page 3
· Single wall containment sumps installed on or after 11/1/2007 that are not monitored continuously for releases using vacuum, pressure, or hydrostatic interstitial monitoring methods and all other containment sumps installed prior to 11/1/2007 that are used for interstitial monitoring can be tightness
tested every three (3) years in accordance with the Dri-sump® testing method.
· If any periodic test fails, a suspected release report must be submitted on a UST-17A form, UST Suspected Release 24 Hour Notice. The suspected
release must be investigated, in accordance with 15A NCAC 2N .0603, and defective equipment repaired or replaced in accordance with 15A NCAC 2N .0404/.0900. Results of the investigation must be submitted on a UST-17B form, UST Suspected Release 7 Day Notice.
· If a UDC / containment sump fails a periodic tightness test, the sump must be replaced or repaired by the manufacturer, or the manufacturer's
authorized representative in accordance with the manufacturer's specifications, or in accordance with a code of practice developed by a nationally recognized association.
UST FACILITY
Owner / Operator Name Facility IDFacility Name
Facility Street Address Facility City County
TESTING CONTRACTOR INFORMATION
Company Name Phone Email address
I certify, under penalty of law, that the testing data provided on this form documents the UST system equipment was checked in accordance with the
manufacturer's guidelines and the applicable national industry standards listed in 15A NCAC 2N .406 and/or 15A NCAC 2N .0900, or another method approved by NC DEQ.
Print Name of person conducting test Signature of person conducting test Test Date
Tester Certification #:
Tester Certification Expiration:
Equipment Certification #:
Equipment Certification Expiration:
Identify UDC/sump (By
Dispenser No. Transition Sump
No. or Tank No., Tank Size, Stored Product; e.g. #1 10k
Regular STP, Disp 1/2, TS-1A etc.)#:
Dispenser
Tank #
Transition
####
Sump Material FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
Liquid and debris removed from sump?Yes No Yes No Yes No Yes No Yes No
Construction SW DW SW DW SW DW SW DW SW DW
Visual inspection (No cracks, loose parts, open penetrations, or separation of the containment sump)
Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Is groundwater above bottom of
sump?Yes No Yes No Yes No Yes No Yes No
VST Communication (Enter
VST number)VSTVST
Closed Hose (C) (in WC)
Open Hose (O) (in WC)
VST Communication Passes when: C > O and C > V and V ≥ O
Test length in seconds
Laser Verification
DOT (Pass)
Line
(Fail)Pass/Fail criteria: Must pass visual inspection. Laser result must be a laser-dot (pass). If the first test fails, then conduct a second test entering results in another column. Test is not valid if liquid or debris was not removed from sump. VST location map must be attached to this report.
Final Test Result Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Comments: (include information on repairs made prior to testing, and recommended follow-up for failed tests)
Date next Containment Sump/UDC integrity test due (required every 3 years)
VST Connected (V) (in WC)
Dispenser
Tank #
Transition
Dispenser
Tank #
Transition
Dispenser
Tank #
Transition
Dispenser
Tank #
Transition
VST VST VST VST VSTVSTVSTVST
DOT (Pass)
Line (Fail)
DOT (Pass)
Line
(Fail)
DOT (Pass)
Line
(Fail)
DOT (Pass)
Line
(Fail)
DOT (Pass)
Line
(Fail)
DOT (Pass)
Line
(Fail)
DOT (Pass)
Line
(Fail)
DOT (Pass)
Line
(Fail)
DOT (Pass)
Line
(Fail)
Pilot Travel Centers 00-0-0000034426Pilot 7971
1343 Rock Barn Road Conover Catawba
Joseph Nitschke 1800-4SPATCO [e-mail]
Joseph Nitschke 03/14/2023
UST-6F/23B Triennial UST Containment Sump / UDC Integrity Testing
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION 1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE [phone] FAX [phone] http://www.wastenotnc.org/5/2020
(DPleakâ Test)Page 4
· Single wall containment sumps installed on or after 11/1/2007 that are not monitored continuously for releases using vacuum, pressure, or hydrostatic interstitial monitoring methods and all other containment sumps installed prior to 11/1/2007 that are used for interstitial monitoring can be tightness
tested every three (3) years in accordance with the DPleakâ sump testing method.
· If any periodic test fails, a suspected release report must be submitted on a UST-17A form, UST Suspected Release 24 Hour Notice. The suspected release must be investigated, in accordance with 15A NCAC 2N .0603, and defective equipment repaired or replaced in accordance with 15A NCAC 2N .0404/.0900. Results of the investigation must be submitted on a UST-17B form, UST Suspected Release 7 Day Notice.
· If a UDC / containment sump fails a periodic tightness test, the sump must be replaced or repaired by the manufacturer, or the manufacturer's authorized representative in accordance with the manufacturer's specifications, or in accordance with a code of practice developed by a nationally
recognized association. UST FACILITY
Owner / Operator Name Facility IDFacility Name
Facility Street Address Facility City County
TESTING CONTRACTOR INFORMATION
Company Name Phone Email address
I certify, under penalty of law, that the testing data provided on this form documents the UST system equipment was checked in accordance with the
manufacturer's guidelines and the applicable national industry standards listed in 15A NCAC 2N .406 and/or 15A NCAC 2N .0900, or another method approved by NC DEQ.
Print Name of person conducting test Signature of person conducting test Test Date
Tester Certification #:
Identify UDC/sump (By
Dispenser No. or Tank Number,
Tank Size, Stored Product; e.g. #1 10k Regular STP, Disp 1/2,
etc.)#:
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
Transition sumps should be listed above as “TS-XX” (with XX= sump ID#)
Sump Material FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
Liquid and debris removed from sump?Yes No Yes No Yes No Yes No Yes No Yes No
Construction SW DW SW DW SW DW SW DW SW DW SW DW
Visual inspection (No cracks, loose parts, open penetrations, or separation of the
containment sump)
Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
North/Rear Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
East/Right Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
South/Front Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
West/Left Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Floor Pass FailN/A Pass FailN/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Electrical/Pen #1 Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
STP/Turbine/Pen #2 Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pen #3/Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pen #4/Pass FailN/A Pass FailN/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/APass/Fail criteria: Must pass visual inspection. Test is not valid if liquid or debris was not removed from sump. No areas of sump that fail.
LDT test report with addendums attached Yes No
Final Test Result Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Comments: (include information on repairs made prior to testing, and recommended follow-up for failed tests)
Date next Containment Sump/UDC integrity test due (required every 3 years)
Pilot Travel Centers 00-0-0000034426Pilot 7971
1343 Rock Barn Road Conover Catawba
Joseph Nitschke 1800-4SPATCO [e-mail]
Joseph Nitschke 03/14/2023
UST-6F/23B Triennial UST Containment Sump / UDC Integrity Testing
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION 1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE [phone] FAX [phone] http://www.wastenotnc.org/5/2020
Page 1 (Full height hydrostatic or vacuum test)
· If any periodic test fails, a suspected release report must be submitted on a UST-17A form, UST Suspected Release 24 Hour Notice. The suspected
release must be investigated, in accordance with 15A NCAC 2N .0603, and defective equipment repaired or replaced in accordance with 15A NCAC 2N .0404/.0900. Results of the investigation must be submitted on a UST-17B form, UST Suspected Release 7 Day Notice.
· Containment sumps installed on or after 11/1/2007 that are not monitored continuously for releases using vacuum, pressure, or hydrostatic interstitial
monitoring methods and all other containment sumps installed prior to 11/1/2007 that are used for interstitial monitoring shall be tightness tested at installation and every three (3) years thereafter in accordance with the manufacturer's written guidelines, PEI/RP100 “Recommended Practices for Installation of Underground Liquid Storage Systems” and/or PEI/RP1200 “Recommended Practices for the Testing and Verification of Spill, Overfill, Leak Detection and Secondary Containment Equipment at UST Facilities.”
· If a UDC / containment sump fails a periodic tightness test, the sump must be replaced or repaired by the manufacturer, or the manufacturer's
authorized representative in accordance with the manufacturer's specifications.
UST FACILITY
Owner / Operator Name Facility IDFacility Name
Facility Street Address Facility City County
CONTRACTOR/PERSON CONDUCTING INSPECTIONS
Company Name Phone Email address
I certify, under penalty of law, that the testing data provided on this form documents the UST system equipment was checked in accordance with the manufacturer's guidelines and the applicable national industry standards listed in 15A NCAC 2N .406 and/or 15A NCAC 2N .0900.
Print Name of person conducting test Signature of person conducting test Test Date
Identify UDC/sump (By Dispenser No. or Tank Number,
Tank Size, Stored Product; e.g. #1 10k Regular STP, Disp 1/2,
etc.)#:
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
Transition sumps should be listed above as “TS-XX” (with XX= sump ID#)
Sump Material FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
Sump Type Single Wall
Double Wall
Single Wall
Double Wall
Single Wall
Double Wall
Single Wall
Double Wall
Single Wall
Double Wall
Single Wall
Double Wall
Test Type Hydrostatic
Vacuum
Hydrostatic
Vacuum
Hydrostatic
Vacuum
Hydrostatic
Vacuum
Hydrostatic
Vacuum
Hydrostatic
Vacuum
Indicate units for all measurements
Liquid and debris removed from sump?Yes No Yes No Yes No Yes No Yes No Yes No
Visual inspection (No cracks, loose parts or separation of the
containment sump)
Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Sump Depth
Height from sump bottom to top of highest penetration or sump
sidewall seam
Wait time between applying
vacuum/water and start of test
Begin ị End Test Time (minimum test time: 1 hour)
Begin ị End values
Pass/Fail criteria: Must pass visual inspection. Hydrostatic: Water level drop of 1/8 inch or more fails the test, Water level must be 4 or more inches above highest penetration or side wall seam or test is invalid; Vacuum: No change in vacuum
Test Results Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Comments: (include information on repairs made prior to testing, and recommended follow-up for failed tests)
Date next Containment Sump/UDC integrity test due (required every 3 years)
Pilot Travel Centers 00-0-0000034426Pilot 7971
1343 Rock Barn Road Conover Catawba
Joseph Nitschke 1800-4SPATCO [e-mail]
Joseph Nitschke 03/14/2023
3 Auto Diesel
36”
18”
20 minutes
13:47 14:47
24”11”
UST-6F/23B Triennial UST Containment Sump / UDC Integrity Testing
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION 1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE [phone] FAX [phone] http://www.wastenotnc.org/5/2020
(Low Liquid Level Test)Page 2
· Containment sumps installed on or after 11/1/2007 that are not monitored continuously for releases using vacuum, pressure, or hydrostatic interstitial monitoring methods and all other containment sumps installed prior to 11/1/2007 that are used for interstitial monitoring can be tightness tested every
three (3) years in accordance with the NCDEQ Low Level Hydrostatic Integrity Test Procedures which can be found on the UST section website at https://deq.nc.gov/about/divisions/waste-management/ust/forms. This method cannot be used for the installation testing of containment sumps.
· If any periodic test fails, a suspected release report must be submitted on a UST-17A form, UST Suspected Release 24 Hour Notice. The suspected release must be investigated, in accordance with 15A NCAC 2N .0603, and defective equipment repaired or replaced in accordance with 15A NCAC 2N .0404/.0900. Results of the investigation must be submitted on a UST-17B form, UST Suspected Release 7 Day Notice.
· If a UDC / containment sump fails a periodic tightness test, the sump must be replaced or repaired by the manufacturer, or the manufacturer's authorized representative in accordance with the manufacturer's specifications.
· Attach all setup reports (e.g. Veeder-Root: Output Relay Setup, Incon: Main console setup) for the sensor alarms positive shut-down to this form. If the
dispenser has a standalone sensor to shut-down the dispenser then annotate on the test form in the comments section.
UST FACILITY
Owner / Operator Name Facility IDFacility Name
Facility Street Address Facility City County
CONTRACTOR/PERSON CONDUCTING INSPECTIONS
Company Name Phone Email address
I certify, under penalty of law, that the testing data provided on this form documents the UST system equipment was checked in accordance with the
manufacturer's guidelines and the applicable national industry standards listed in 15A NCAC 2N .406 and/or 15A NCAC 2N .0900, or another method approved by NC DEQ.
Print Name of person conducting test Signature of person conducting test Test Date
Identify UDC/sump (By
Dispenser No. or Tank Number,
Tank Size, Stored Product; e.g. #1 10k Regular STP, Disp 1/2,
etc.)#:
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
Transition sumps should be listed above as “TS-XX” (with XX= sump ID#)
Sump Material FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
Indicate units for all measurements
Liquid and debris removed from sump?Yes No Yes No Yes No Yes No Yes No Yes No
Is sensor 2” or less from lowest portion of sump bottom?Yes No Yes No Yes No Yes No Yes No Yes No
Visual inspection (No cracks, loose parts or separation of the
containment sump)
Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Did sensor alarm when tested?Yes No Yes No Yes No Yes No Yes No Yes No
If sensor alarms, did the STP and/or dispenser shut-off? Note for dispenser sensors all product types in the dispenser must be disabled.
Yes No Yes No Yes No Yes No Yes No Yes No
Level above bottom of sump where sensor alarms (inches)
Wait time between applying water and start of test
Begin ị End Test Time (minimum test time: 1 hour)
Begin ị End values
Pass/Fail criteria: Any No or Fail in the above, the sump fails the test . Hydrostatic: Water level drop of 1/8 inch or more fails the test.
Test Results Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Comments: (include information on repairs made prior to testing, and recommended follow-up for failed tests)
Date next Containment Sump/UDC integrity test due (required every 3 years)
Pilot Travel Centers 00-0-0000034426Pilot 7971
1343 Rock Barn Road Conover Catawba
Joseph Nitschke 1800-4SPATCO [e-mail]
Joseph Nitschke 03/14/2023
UST-6F/23B Triennial UST Containment Sump / UDC Integrity Testing
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION 1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE [phone] FAX [phone] http://www.wastenotnc.org/5/2020
(Dri-Sump® Test)Page 3
· Single wall containment sumps installed on or after 11/1/2007 that are not monitored continuously for releases using vacuum, pressure, or hydrostatic interstitial monitoring methods and all other containment sumps installed prior to 11/1/2007 that are used for interstitial monitoring can be tightness
tested every three (3) years in accordance with the Dri-sump® testing method.
· If any periodic test fails, a suspected release report must be submitted on a UST-17A form, UST Suspected Release 24 Hour Notice. The suspected
release must be investigated, in accordance with 15A NCAC 2N .0603, and defective equipment repaired or replaced in accordance with 15A NCAC 2N .0404/.0900. Results of the investigation must be submitted on a UST-17B form, UST Suspected Release 7 Day Notice.
· If a UDC / containment sump fails a periodic tightness test, the sump must be replaced or repaired by the manufacturer, or the manufacturer's
authorized representative in accordance with the manufacturer's specifications, or in accordance with a code of practice developed by a nationally recognized association.
UST FACILITY
Owner / Operator Name Facility IDFacility Name
Facility Street Address Facility City County
TESTING CONTRACTOR INFORMATION
Company Name Phone Email address
I certify, under penalty of law, that the testing data provided on this form documents the UST system equipment was checked in accordance with the
manufacturer's guidelines and the applicable national industry standards listed in 15A NCAC 2N .406 and/or 15A NCAC 2N .0900, or another method approved by NC DEQ.
Print Name of person conducting test Signature of person conducting test Test Date
Tester Certification #:
Tester Certification Expiration:
Equipment Certification #:
Equipment Certification Expiration:
Identify UDC/sump (By
Dispenser No. Transition Sump
No. or Tank No., Tank Size, Stored Product; e.g. #1 10k
Regular STP, Disp 1/2, TS-1A etc.)#:
Dispenser
Tank #
Transition
####
Sump Material FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
Liquid and debris removed from sump?Yes No Yes No Yes No Yes No Yes No
Construction SW DW SW DW SW DW SW DW SW DW
Visual inspection (No cracks, loose parts, open penetrations, or separation of the containment sump)
Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Is groundwater above bottom of
sump?Yes No Yes No Yes No Yes No Yes No
VST Communication (Enter
VST number)VSTVST
Closed Hose (C) (in WC)
Open Hose (O) (in WC)
VST Communication Passes when: C > O and C > V and V ≥ O
Test length in seconds
Laser Verification
DOT (Pass)
Line
(Fail)Pass/Fail criteria: Must pass visual inspection. Laser result must be a laser-dot (pass). If the first test fails, then conduct a second test entering results in another column. Test is not valid if liquid or debris was not removed from sump. VST location map must be attached to this report.
Final Test Result Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Comments: (include information on repairs made prior to testing, and recommended follow-up for failed tests)
Date next Containment Sump/UDC integrity test due (required every 3 years)
VST Connected (V) (in WC)
Dispenser
Tank #
Transition
Dispenser
Tank #
Transition
Dispenser
Tank #
Transition
Dispenser
Tank #
Transition
VST VST VST VST VSTVSTVSTVST
DOT (Pass)
Line (Fail)
DOT (Pass)
Line
(Fail)
DOT (Pass)
Line
(Fail)
DOT (Pass)
Line
(Fail)
DOT (Pass)
Line
(Fail)
DOT (Pass)
Line
(Fail)
DOT (Pass)
Line
(Fail)
DOT (Pass)
Line
(Fail)
DOT (Pass)
Line
(Fail)
Pilot Travel Centers 00-0-0000034426Pilot 7971
1343 Rock Barn Road Conover Catawba
Joseph Nitschke 1800-4SPATCO [e-mail]
Joseph Nitschke 03/14/2023
UST-6F/23B Triennial UST Containment Sump / UDC Integrity Testing
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION 1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE [phone] FAX [phone] http://www.wastenotnc.org/5/2020
(DPleakâ Test)Page 4
· Single wall containment sumps installed on or after 11/1/2007 that are not monitored continuously for releases using vacuum, pressure, or hydrostatic interstitial monitoring methods and all other containment sumps installed prior to 11/1/2007 that are used for interstitial monitoring can be tightness
tested every three (3) years in accordance with the DPleakâ sump testing method.
· If any periodic test fails, a suspected release report must be submitted on a UST-17A form, UST Suspected Release 24 Hour Notice. The suspected release must be investigated, in accordance with 15A NCAC 2N .0603, and defective equipment repaired or replaced in accordance with 15A NCAC 2N .0404/.0900. Results of the investigation must be submitted on a UST-17B form, UST Suspected Release 7 Day Notice.
· If a UDC / containment sump fails a periodic tightness test, the sump must be replaced or repaired by the manufacturer, or the manufacturer's authorized representative in accordance with the manufacturer's specifications, or in accordance with a code of practice developed by a nationally
recognized association. UST FACILITY
Owner / Operator Name Facility IDFacility Name
Facility Street Address Facility City County
TESTING CONTRACTOR INFORMATION
Company Name Phone Email address
I certify, under penalty of law, that the testing data provided on this form documents the UST system equipment was checked in accordance with the
manufacturer's guidelines and the applicable national industry standards listed in 15A NCAC 2N .406 and/or 15A NCAC 2N .0900, or another method approved by NC DEQ.
Print Name of person conducting test Signature of person conducting test Test Date
Tester Certification #:
Identify UDC/sump (By
Dispenser No. or Tank Number,
Tank Size, Stored Product; e.g. #1 10k Regular STP, Disp 1/2,
etc.)#:
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
#
Dispenser
Tank #
Transition sumps should be listed above as “TS-XX” (with XX= sump ID#)
Sump Material FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
FRP
Plastic
Liquid and debris removed from sump?Yes No Yes No Yes No Yes No Yes No Yes No
Construction SW DW SW DW SW DW SW DW SW DW SW DW
Visual inspection (No cracks, loose parts, open penetrations, or separation of the
containment sump)
Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
North/Rear Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
East/Right Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
South/Front Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
West/Left Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Floor Pass FailN/A Pass FailN/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Electrical/Pen #1 Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
STP/Turbine/Pen #2 Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pen #3/Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pen #4/Pass FailN/A Pass FailN/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/APass/Fail criteria: Must pass visual inspection. Test is not valid if liquid or debris was not removed from sump. No areas of sump that fail.
LDT test report with addendums attached Yes No
Final Test Result Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Comments: (include information on repairs made prior to testing, and recommended follow-up for failed tests)
Date next Containment Sump/UDC integrity test due (required every 3 years)
Pilot Travel Centers 00-0-0000034426Pilot 7971
1343 Rock Barn Road Conover Catawba
Joseph Nitschke 1800-4SPATCO [e-mail]
Joseph Nitschke 03/14/2023
Site Information
Service #000005061232 PO #160163869
PILOT #7971 Customer #0001003322
1343 ROCK BARN RD
CONOVER, NC 28613
Work Performed by Jordan Fearrington
ECHM JF
03/13/23

Arrived on site and met service tech already on site. Opened up DSL STP sump and located
leaking flex line. Cut flex line in half and broke loose flex from fiberglass elbow. Found
existing ball valve to be bad so removed it as well. Removed existing union coming out of STP.
Replaced leaking flex line and bad ball valve and re-piped back to STP using a new union.
Verified no leaks. Opened site back up, cleaned up and checked out with MOD.
Time On Site
Time Arrived: 3/13/23, 9:00 PM
Time Departed: 3/14/23, 12:00 AM
Total Time on Site: 3 hours
Follow-up Required?
No followup required.
Customer Signature
Jordan Fearrington
3/14/23, 12:02 AM
Site Information
Service #000005061232 PO #160163869
PILOT #7971 Customer #0001003322
1343 ROCK BARN RD
CONOVER, NC 28613
Work Performed by Carl Corke
ECHM-CC-arrived on site and checked in. Disassembled piping from DSL STP union back to the
product line. Re-piped from product piping to DSL STP. Restored power to DSL STP, opened ball
valve and checked for leaks. Cleaned up site before leaving.
Time On Site
Time Arrived: 3/13/23, 9:00 PM
Time Departed: 3/14/23, 12:00 AM
Total Time on Site: 3 hours
Follow-up Required?
No followup required.
Customer Signature
Carl Corke
3/14/23, 12:01 AM

ATTACHMENT II
04-20-2023 S:\Enviro\Pilot\PIlot 7971 - Conover\Boring Logs\SB-1.borClient: Pilot
Conover, Catawaba County, North Carolina
1343 Rock Barn Road
Pantry # 7971
SOIL BORING: SB-1
(Page 1 of 1)Depth in Feet (BGS)0
1
2
3
4
5
6
7
8
9
10
11
12
13 USCSAR
ML
ML
ML
ML
ML
ML GRAPHICDESCRIPTION
Asphalt
REd Clayey SILT
Red to orange SILT.
Orange SILT
Brown SILT with mica
Brown and white SILT with pebbles
Brown SILT with mica
Bottom of boring.
PID
(ppm)
0.0
0.0
0.0
0.0
0.0
0.0
bgs = below ground surface.
Soil sample SB-1 collected at 13 feet bgs.
ppm = Parts Per Million.
Date(s) Drilled : 4/13/2023
Drilling Contractor : AmeriProbe
Drilling Method : Hand Auger
: Direct Push Technology
Boring Diameter : 2.25"
Sampling Method : Macrocore
Sampling Invertal : Continuous
Logged By : Nathan Reel

ATTACHMENT III
ANALYTICAL REPORT
April 19, 2023
ATC Group - Pangean CMD - Woodstock, GA
Sample Delivery Group:L1605551
Samples Received:04/14/2023
Project Number:
Description:Pilot 7971
Report To:Maureen Jackson
2725 E. Millbrook Road
Suite 121
Raleigh, NC 27604
Entire Report Reviewed By:
April 19, 2023
[Preliminary Report]
Jeff Carr
Project Manager
Results relate only to the items tested or calibrated and are reported as rounded values. This test report shall not be reproduced, except in full, without written approval of the laboratory. Where applicable, sampling conducted by Pace Analytical National is performed per guidance provided in laboratory standard operating procedures ENV-SOP-MTJL-0067 and ENV-SOP-MTJL-0068. Where sampling conducted by the customer, results relate to the accuracy of the information provided, and as the samples are received.
Pace Analytical National
12065 Lebanon Rd Mount Juliet, TN 37122 615-758-5858 800-767-5859 www.pacenational.com
1 Cp
2Tc
3Ss
4Cn
5Sr
6Qc
7Gl
8Al
9Sc
ACCOUNT:PROJECT:SDG:DATE/TIME:PAGE:
ATC Group - Pangean CMD - Woodstock, GA L1605551 04/19/23 18:13 1 of 11
April 19, 2023
Jeff Carr
Project Manager
ACCOUNT:PROJECT:SDG:DATE/TIME:PAGE:
ATC Group - Pangean CMD - Woodstock, GA L1605551 04/19/23 19:40 1 of 11
TABLE OF CONTENTS
Cp: Cover Page 1
Tc: Table of Contents 2
Ss: Sample Summary 3
Cn: Case Narrative 4
Sr: Sample Results 5
SB-1 (13') L1605551-01 5
Qc: Quality Control Summary 6
Total Solids by Method 2540 G-2011 6
Volatile Organic Compounds (GC) by Method 8015D/GRO 7
Semi-Volatile Organic Compounds (GC) by Method 8015C 8
Gl: Glossary of Terms 9
Al: Accreditations & Locations 10
Sc: Sample Chain of Custody 11
1 Cp
2Tc
3Ss
4Cn
5Sr
6Qc
7Gl
8Al
9Sc
ACCOUNT:PROJECT:SDG:DATE/TIME:PAGE:
ATC Group - Pangean CMD - Woodstock, GA L1605551 04/19/23 18:13 2 of 11
ACCOUNT:PROJECT:SDG:DATE/TIME:PAGE:
ATC Group - Pangean CMD - Woodstock, GA L1605551 04/19/23 19:40 2 of 11
SAMPLE SUMMARY
Collected by Collected date/time Received date/time
SB-1 (13') L1605551-01 Solid Nathan Reel 04/13/23 09:10 04/14/23 09:15
Method Batch Dilution Preparation Analysis Analyst Location
date/time date/time
Total Solids by Method 2540 G-2011 WG2042549 1 04/15/23 13:10 04/15/23 13:26 CMK Mt. Juliet, TN
Volatile Organic Compounds (GC) by Method 8015D/GRO WG2043931 25 04/17/23 12:56 04/18/23 16:27 KSD Mt. Juliet, TN
Semi-Volatile Organic Compounds (GC) by Method 8015C WG2042915 1 04/15/23 11:07 04/16/23 10:11 KAP Mt. Juliet, TN
1 Cp
2Tc
3Ss
4Cn
5Sr
6Qc
7Gl
8Al
9Sc
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CASE NARRATIVE
All sample aliquots were received at the correct temperature, in the proper containers, with the
appropriate preservatives, and within method specified holding times, unless qualified or notated within
the report. Where applicable, all MDL (LOD) and RDL (LOQ) values reported for environmental samples
have been corrected for the dilution factor used in the analysis. All Method and Batch Quality Control
are within established criteria except where addressed in this case narrative, a non-conformance form
or properly qualified within the sample results. By my digital signature below, I affirm to the best of my
knowledge, all problems/anomalies observed by the laboratory as having the potential to affect the
quality of the data have been identified by the laboratory, and no information or data have been
knowingly withheld that would affect the quality of the data.
[Preliminary Report]
Jeff Carr
Project Manager
1 Cp
2Tc
3Ss
4Cn
5Sr
6Qc
7Gl
8Al
9Sc
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Jeff Carr
Project Manager
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SAMPLE RESULTS - 01
L1605551
SB-1 (13')
Collected date/time: 04/13/23 09:10
Total Solids by Method 2540 G-2011
Result Qualifier Dilution Analysis Batch
Analyte %date / time
Total Solids 65.8 1 04/15/2023 13:26 WG2042549
Volatile Organic Compounds (GC) by Method 8015D/GRO
Result (dry)Qualifier MDL (dry)RDL (dry)Dilution Analysis Batch
Analyte mg/kg mg/kg mg/kg date / time
TPH (GC/FID) Low Fraction U 1.11 5.11 25 04/18/2023 16:27 WG2043931
(S) a,a,a-Trifluorotoluene(FID)92.2 77.0-120 04/18/2023 16:27 WG2043931
Semi-Volatile Organic Compounds (GC) by Method 8015C
Result (dry)Qualifier MDL (dry)RDL (dry)Dilution Analysis Batch
Analyte mg/kg mg/kg mg/kg date / time
TPH (GC/FID) High Fraction 1.22 J 1.17 6.08 1 04/16/2023 10:11 WG2042915
(S) o-Terphenyl 48.9 18.0-148 04/16/2023 10:11 WG2042915
1 Cp
2Tc
3Ss
4Cn
5Sr
6Qc
7Gl
8Al
9Sc
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QUALITY CONTROL SUMMARYWG2042549
Total Solids by Method 2540 G-2011 L1605551-01
Method Blank (MB)
(MB) R3913851-1 04/15/23 13:26
MB Result MB Qualifier MB MDL MB RDL
Analyte %%%
Total Solids 0.00100
L1605555-01 Original Sample (OS) • Duplicate (DUP)
(OS) L1605555-01 04/15/23 13:26 • (DUP) R3913851-3 04/15/23 13:26
Original Result DUP Result Dilution DUP RPD DUP Qualifier DUP RPD
Limits
Analyte %%%%
Total Solids 88.9 87.0 1 2.19 10
Laboratory Control Sample (LCS)
(LCS) R3913851-2 04/15/23 13:26
Spike Amount LCS Result LCS Rec.Rec. Limits LCS Qualifier
Analyte %%%%
Total Solids 50.0 50.0 100 85.0-115
1 Cp
2Tc
3Ss
4Cn
5Sr
6Qc
7Gl
8Al
9Sc
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QUALITY CONTROL SUMMARYWG2043931
Volatile Organic Compounds (GC) by Method 8015D/GRO L1605551-01
Method Blank (MB)
(MB) R3915017-2 04/18/23 13:43
MB Result MB Qualifier MB MDL MB RDL
Analyte mg/kg mg/kg mg/kg
TPH (GC/FID) Low Fraction U 0.543 2.50
(S)
a,a,a-Trifluorotoluene(FID)92.1 77.0-120
Laboratory Control Sample (LCS)
(LCS) R3915017-1 04/18/23 12:58
Spike Amount LCS Result LCS Rec.Rec. Limits LCS Qualifier
Analyte mg/kg mg/kg %%
TPH (GC/FID) Low Fraction 5.50 4.21 76.5 72.0-127
(S)
a,a,a-Trifluorotoluene(FID) 101 77.0-120
1 Cp
2Tc
3Ss
4Cn
5Sr
6Qc
7Gl
8Al
9Sc
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QUALITY CONTROL SUMMARYWG2042915
Semi-Volatile Organic Compounds (GC) by Method 8015C L1605551-01
Method Blank (MB)
(MB) R3913711-1 04/16/23 09:06
MB Result MB Qualifier MB MDL MB RDL
Analyte mg/kg mg/kg mg/kg
TPH (GC/FID) High Fraction U 0.769 4.00
(S) o-Terphenyl 32.7 18.0-148
Laboratory Control Sample (LCS)
(LCS) R3913711-2 04/16/23 09:19
Spike Amount LCS Result LCS Rec.Rec. Limits LCS Qualifier
Analyte mg/kg mg/kg %%
TPH (GC/FID) High Fraction 50.0 26.0 52.0 50.0-150
(S) o-Terphenyl 60.7 18.0-148
1 Cp
2Tc
3Ss
4Cn
5Sr
6Qc
7Gl
8Al
9Sc
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GLOSSARY OF TERMS
Guide to Reading and Understanding Your Laboratory Report
The information below is designed to better explain the various terms used in your report of analytical results from the Laboratory. This is not
intended as a comprehensive explanation, and if you have additional questions please contact your project representative.
Results Disclaimer - Information that may be provided by the customer, and contained within this report, include Permit Limits, Project Name,
Sample ID, Sample Matrix, Sample Preservation, Field Blanks, Field Spikes, Field Duplicates, On-Site Data, Sampling Collection Dates/Times, and
Sampling Location. Results relate to the accuracy of this information provided, and as the samples are received.
Abbreviations and Definitions
(dry)Results are reported based on the dry weight of the sample. [this will only be present on a dry report basis for soils].
MDL Method Detection Limit.
MDL (dry)Method Detection Limit.
RDL Reported Detection Limit.
RDL (dry)Reported Detection Limit.
Rec.Recovery.
RPD Relative Percent Difference.
SDG Sample Delivery Group.
(S)
Surrogate (Surrogate Standard) - Analytes added to every blank, sample, Laboratory Control Sample/Duplicate and
Matrix Spike/Duplicate; used to evaluate analytical efficiency by measuring recovery. Surrogates are not expected to be
detected in all environmental media.
U Not detected at the Reporting Limit (or MDL where applicable).
Analyte The name of the particular compound or analysis performed. Some Analyses and Methods will have multiple analytes
reported.
Dilution
If the sample matrix contains an interfering material, the sample preparation volume or weight values differ from the
standard, or if concentrations of analytes in the sample are higher than the highest limit of concentration that the
laboratory can accurately report, the sample may be diluted for analysis. If a value different than 1 is used in this field, the
result reported has already been corrected for this factor.
Limits
These are the target % recovery ranges or % difference value that the laboratory has historically determined as normal
for the method and analyte being reported. Successful QC Sample analysis will target all analytes recovered or
duplicated within these ranges.
Original Sample The non-spiked sample in the prep batch used to determine the Relative Percent Difference (RPD) from a quality control
sample. The Original Sample may not be included within the reported SDG.
Qualifier
This column provides a letter and/or number designation that corresponds to additional information concerning the result
reported. If a Qualifier is present, a definition per Qualifier is provided within the Glossary and Definitions page and
potentially a discussion of possible implications of the Qualifier in the Case Narrative if applicable.
Result
The actual analytical final result (corrected for any sample specific characteristics) reported for your sample. If there was
no measurable result returned for a specific analyte, the result in this column may state “ND” (Not Detected) or “BDL”
(Below Detectable Levels). The information in the results column should always be accompanied by either an MDL
(Method Detection Limit) or RDL (Reporting Detection Limit) that defines the lowest value that the laboratory could detect
or report for this analyte.
Uncertainty
(Radiochemistry)Confidence level of 2 sigma.
Case Narrative (Cn)
A brief discussion about the included sample results, including a discussion of any non-conformances to protocol
observed either at sample receipt by the laboratory from the field or during the analytical process. If present, there will
be a section in the Case Narrative to discuss the meaning of any data qualifiers used in the report.
Quality Control
Summary (Qc)
This section of the report includes the results of the laboratory quality control analyses required by procedure or
analytical methods to assist in evaluating the validity of the results reported for your samples. These analyses are not
being performed on your samples typically, but on laboratory generated material.
Sample Chain of
Custody (Sc)
This is the document created in the field when your samples were initially collected. This is used to verify the time and
date of collection, the person collecting the samples, and the analyses that the laboratory is requested to perform. This
chain of custody also documents all persons (excluding commercial shippers) that have had control or possession of the
samples from the time of collection until delivery to the laboratory for analysis.
Sample Results (Sr)
This section of your report will provide the results of all testing performed on your samples. These results are provided
by sample ID and are separated by the analyses performed on each sample. The header line of each analysis section for
each sample will provide the name and method number for the analysis reported.
Sample Summary (Ss)This section of the Analytical Report defines the specific analyses performed for each sample ID, including the dates and
times of preparation and/or analysis.
Qualifier Description
J The identification of the analyte is acceptable; the reported value is an estimate.
1 Cp
2Tc
3Ss
4Cn
5Sr
6Qc
7Gl
8Al
9Sc
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Pace Analytical National 12065 Lebanon Rd Mount Juliet, TN 37122
Alabama 40660 Nebraska NE-OS-15-05
Alaska 17-026 Nevada TN000032021-1
Arizona AZ0612 New Hampshire 2975
Arkansas 88-0469 New Jersey–NELAP TN002
California 2932 New Mexico ¹TN00003
Colorado TN00003 New York 11742
Connecticut PH-0197 North Carolina Env375
Florida E87487 North Carolina ¹DW21704
Georgia NELAP North Carolina ³41
Georgia ¹923 North Dakota R-140
Idaho TN00003 Ohio–VAP CL0069
Illinois 200008 Oklahoma 9915
Indiana C-TN-01 Oregon TN200002
Iowa 364 Pennsylvania 68-02979
Kansas E-10277 Rhode Island LAO00356
Kentucky ¹ ⁶KY90010 South Carolina 84004002
Kentucky ²16 South Dakota n/a
Louisiana AI30792 Tennessee ¹ ⁴2006
Louisiana LA018 Texas T104704245-20-18
Maine TN00003 Texas ⁵LAB0152
Maryland 324 Utah TN000032021-11
Massachusetts M-TN003 Vermont VT2006
Michigan 9958 Virginia 110033
Minnesota 047-999-395 Washington C847
Mississippi TN00003 West Virginia 233
Missouri 340 Wisconsin 998093910
Montana CERT0086 Wyoming A2LA
A2LA – ISO 17025 1461.01 AIHA-LAP,LLC EMLAP 100789
A2LA – ISO 17025 ⁵1461.02 DOD 1461.01
Canada 1461.01 USDA P330-15-00234
EPA–Crypto TN00003
ACCREDITATIONS & LOCATIONS

¹ Drinking Water ² Underground Storage Tanks ³ Aquatic Toxicity ⁴ Chemical/Microbiological ⁵ Mold ⁶ Wastewater n/a Accreditation not applicable
* Not all certifications held by the laboratory are applicable to the results reported in the attached report.
* Accreditation is only applicable to the test methods specified on each scope of accreditation held by Pace Analytical.
1 Cp
2Tc
3Ss
4Cn
5Sr
6Qc
7Gl
8Al
9Sc
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