MO-9412_40858_CA_UST-61_20181203_24-Hour Release & 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) N
Facility ID Number 0-035443
Incident # Risk (H,I,L,U)
Confirmed GW Contamination? (Y/N) N
Date Leak Discovered
Received On Received By
Confirmed Soil Contamination ?(Y/N) Y
Comm/Non-Commercial?
Reported by (circle one): Phone, Fax or Report
Samples Taken?(Y/N) fir
Reg/Non-regulated? Reg
Region
Free Product? (Y/N) ___N_ If Yes, State Greatest
Thickness NA
INCIDENT DESCRIPTION
Incident Name:
S sco Charlotte LLC.
Address: 4500 Corporate Drive NW
County: Cabarrus
City/Town: Concord
Zip Code: 28027
Regional Office (circle one): Asheville, Mooresville, Fayetteville,
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): 35.423278 N Longitude (decimal degrees) : 80.651474 W
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
❑ GIS Address matching
Other
❑ Unknown
During a Site Check on November 1, 2018, soil samples were collected from
soil borings at the dispenser # 1/2 sump and STP sump for the 20,000- allon
diesel UST. Laboratory analytical results received on November 9, 2018
confirmed a reportable release at the dispenser # 1/2 sump.
Describe location:
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) Site Check
SOURCE OF CONTAMINATION
Source of Release Cause of Release Type of Release Product Type Released
(Check one to indicate primary (Check one to indicate primary (Check one) (Check one to indicate primary product type
source) cause) released)
❑ Tank Spill Petroleum A Gasoline/ Diesel/ ❑ Diesel/Veg. Oil
Kerosene Blend
❑ Piping ❑Overfill ❑Non -Petroleum ❑
❑
Heating Oil Vegetable Oil 100%
Dispenser ❑ Corrosion ❑ Both ❑ Other Petroleum ❑ El 0 — E20
❑ Submersible Turbine Pump ❑ Physical or Mechanical Products
❑ E21 E84
—
Damage Location ❑ Metals
❑ Delivery Problem ❑ E85 E99
❑
coOther Inorganics —
❑ Install Problem (Chekne )
❑
Other ❑ Other ❑ Other Organics ❑ Ethanol 100%
� Facility
❑ Unknown
❑ Unknown ❑ Residence ❑ E01 — E09
Definitions presented on reverse I Definitions presented on reverse I ❑ Other
Ownership
1. Municipal 2. Military 3. Unknown 4. Private 5. Federal 6. County 7. State
Operation Type
1. Public Service 2. Agricultural 3. Residential 4. Education/Relig. 5. Industrial 6. Commercial 7. Mining
UST Form 61 (02/08) Page 1 of 2

IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected? 1. Yes
2. No 3. Unknown
Number of Water Supply Wells Affected
Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
1.
2.
3.
UST SYSTEM OWNER
UST Owner/Company
S sco Charlotte, LLC.
Point of Contact
Address
Josh Callahan
4500 Corporate Drive NW
City
State
Zip Code
Telephone Number
Concord
NC
28027
704-723-6067
UST SYSTEM OPERATOR
UST Operator/Company
Address
S sco Charlotte LLC.
4500 Corporate Drive NW
City
State
Zip Code
Telephone Number
Concord
NC
28027
704-723-6067
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
Address
Sysco Charlotte, LLC.
4500 Corporate Drive NW
City
State
Zip Code
Telephone Number
Concord
NC
28027
704-723-6067
Draw Sketch of Area (showing two major road intersections) or Attach Map
Person Reporting Incident Coiey N. BUcahan Agent
Company Geological Resources Inc.
Telephone Number 704-845-4010
Title P.G., Project Manager
Address3502 Hayes Road, Monroe, NC 28110
Date 11/9/18
UST Form 61 (02/08)
Page 2 of 2
Definitions of Sources
Tank: means the tank that stores the product and is part of the underground storage tank system
Piping: means the piping and connectors running from the tank or submersible turbine pump to the dispenser or other end -use equipment (Vent, vapor recovery, or fill
lines are excluded.)
Dispenser: includes the dispenser and the equipment used to connect the dispenser to the piping (e.g., a release from a suction pump or from components located above
the shear valve)
Submersible Turbine Pump (STP) Area includes the submersible turbine pump head (typically located in the tank sump), the line leak detector, and the piping that
connects the submersible turbine pump to the tank
Delivery Problem: identifies releases that occurred during product delivery to the tank. (Typical causes associated with this source are spills and overfills.)
Other: serves as the option to use when the release source is known but does not fit into one of the preceding categories (e.g., for releases from vent lines, vapor
recovery lines, and fill lines)
Unknown: identifies releases for which the source has not been determined
Definitions of Causes
Spill: use this cause when a spill occurs (e.g., when the delivery hose is disconnected from the tank fill pipe or when the nozzle is removed from the dispenser)
Overfill: use when an overfill occurs (e.g., overfills may occur from the fill pipe at the tank or when the nozzle fails to shut off at the dispenser)
Physical or Mechanical Damage: use for all types of physical or mechanical damage, except corrosion (e.g., puncture of tank or piping, loose fittings, broken
components, and components that have changed dimension)
Corrosion: use when a metal tank, piping, or other component has a release due to corrosion (e.g., for steel, corrosion takes the form of rust)
Installation Problem: use when the problem is determined to have occurred specifically because the UST system was not installed properly
Other: use this option when the cause is known but does not fit into one of the preceding categories (e.g., putting regulated substances into monitoring wells)
Unknown: use when the cause has not been determined

Beverly, Trudy
From: Beverly, Trudy
Sent: Monday, December 17, 2018 6:32 AM
To: 'Corey Buchanan'
Subject: RE: [External] Sysco Charlotte, LLC, Concord #40858
Please submit document in accordance with the February 2018 policies.
Document Submittal & UST File Names for Laserfiche Policies:
httr)s://files.nc.eov/ncdea/Waste%20Manaaement/DWM/UST/Corrective%2OAction/Electronic%2ODocument%2OSubmi
ttal%20Memo%2OUpdate.pdf
httns://files.nc. tiov/ncdea/Waste%20Manaizement/DWM/UST/Corrective%2OAction/UST°/`20file%20names%20for%20
Laserfiche.docx
Trudy
NEsa:r � ;auxx:xn
Trudy Beverly, L.G.
Hydrogeologist, Divisionof Waste Management
North Carolina Department of Environment Quality
Underground Storage Tanks Section
Corrective Action Branch
Mooresville Regional Office
[phone] (Office)
T rudv . B everly na, ncdenr. you
Erna C BSp t7C2 to aw ft70> n this am*$$ is subject to the
Nodh Carolina PUbkc Re=ds Law and may be dw0sed to third part+es.
From: Corey Buchanan[mailto:[e-mail]]
Sent: Friday, December 14, 2018 4:31 PM
To: Beverly, Trudy <[e-mail]>
Subject: Re: [External] Sysco Charlotte, LLC, Concord #40858
• rnal email. Do not click links or open attachments unless verified. Send all suspicious email as an attachment to
OK jack struts received hard copy. Here is the electronic copy for now
From: Beverly, Trudy <[e-mail]>
Sent: Friday, December 14, 2018 4:06:36 PM
To: Corey Buchanan
Subject: RE: [External] Sysco Charlotte, LLC, Concord #40858
I was only forwarded the UST-61 today (Friday, December 14, 2018 12:36 PM). So, I've have not issued the NORR.
The requirements of Title 15A NCAC 2L .0405 include the preparation and submittal of a
Limited Site Assessment (LSA) Report, in accordance with the rule and the most recent version of the
Guidelines for Assessment and Corrective Action for UST Releases, within 120 days of discovery of the
release.

Trudy
Trudy" B avn v-L.G.
14&ogeofogis1 DiVLSbonof -Vm16 an%Tmov
North Carohm Depwtmmt c f En-,7rmwent Quality
Undefguimd Storage Tsnks Secti-m
Corrective etionBrmch
hivoresille L egionsl Office
(70-4) 23 ]-2152 (Office)
Trudy-.B eVeftV- 4 nCdenr. E07
oSysmrtKnl-O! D�E
Fy
Euiad to 4W fr r7 UW$ aoVross rS swbjCCt * tho
Nod?i C rofm Pubkc Pe ds Law a+rior may be dwAosed to thurd part+es.
From: Corey Buchanan[mailto:[e-mail]]
Sent: Friday, December 14, 2018 4:02 PM
To: Beverly, Trudy <[e-mail]>
Subject: Re: [External] Sysco Charlotte, LLC, Concord #40858
No problem its Friday.
Has a NORR been issued for this site. Just wondering so I know what the time line is for scheduling purposes,
thanks.
From: Beverly, Trudy <[e-mail]>
Sent: Friday, December 14, 2018 3:58:40 PM
To: Corey Buchanan
Subject: RE: [External] Sysco Charlotte, LLC, Concord #40858
Corey,
I apologize. My mind was on a spill that I was waiting for additional information before it could be listed in the
database. The incident number and site name for Sysco are below.
Incident Name: Sysco Charlotte, LLC
UST Number: MO-9412
Incident Number: 40858
Have a great weekend,
Trudy
Trud�-B ec-erl�-..L.C1.
A}&ogwbgist Division of -Waste Mcmg epmm
North Carohna Dep t of Environment Quality
Undergfound Storage Tanks Secti-m
Correcti--e ActionErmch
oorewme Regional O►iftce
(70-4) 23 5-2152 (mice)
Trudy-.13 --t-orty- ^=dmr. traeg
D,.E QO"�
er.iw+i s� �e�naM au+Nki��/

Enled Cvflvw O�ncGe tv and Wm this address +,5 57ub)oV to the
Nodhr C n)lo-a Pjbko Records taw arid imm v be err kpsed to third parties.
From: Corey Buchanan [mailto:[e-mail]]
Sent: Friday, December 14, 2018 2:37 PM
To: Beverly, Trudy <[e-mail]>
Subject: Re: [External] sysco, concord
nks or open attachments unless verified. Send all suspicious email as an attachment to
Ron taraban has already received the 61 form. What else is needed?
Sent from my iPhone
On Dec 14, 2018, at 2:35 PM, Beverly, Trudy <trudy.beverly(rc,ncdenr.gov> wrote:
No problem. An incident number will be assigned when documentation is submitted supporting adding
the incident into the UST database.
Trudy
<image010.png><i m age011 J pg>
<image012.png>
From: Corey Buchanan [mailto:[e-mail]]
Sent: Friday, December 14, 2018 2:23 PM
To: Beverly, Trudy <[e-mail]>
Subject: Re: [External] sysco, concord
OK thanks.
Can you give me the incident number once you assign one, thanks.
Best Regards,
Corey N. Buchanan, P.G.
Project Manager
Geological Resources, Inc.
3502 Hayes Road
Monroe, NC 28110
Main [phone] Cell [phone] Fax [phone]
www.geologicalresourcesinc.com
NCPCM 2015 Vendor of the Year Recipient
Business North Carolina Magazine 2015 Small Business of the Year Runner-uo Recipient
9

From: Beverly, Trudy <[e-mail]>
Sent: Friday, December 14, 2018 12:49:26 PM
To: Newton, Brad; Corey Buchanan
Subject: RE: [External] sysco, concord
Hi Corey,
I address sites in Cabarrus County. At the following link you will find the tables, appendices, and action
memo of the Guidelines for Assessment and Corrective Action for UST Releases.
https://deg.nc.gov/about/divisions/waste-management/ust/guidance-documents
The text and figures are under revision. It may be some time before the text and figures are available on
the webpage. The most recent version of the text and figures that I have is from October 1, 2012
(attached). You will have to piece it together with the tables, appendices, and action memo from the
link above. These documents provide detailed information of Limited Site Assessment requirements.
Trudy
<image005.png><i mage007.jpg>
<image008.png>
Branch's Underground Storage Tanks Website Address: https://deg.nc.gov/about/divisions/waste-
management/ust
Branch's Above Ground Storage Tanks Website Address: https://deg.nc.gov/about/divisions/waste-
management/ust/ast-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
https://deg.nc.gov/about/divisions/waste-management/waste-management-rules-data/waste-
management-gis-maps
File Review Procedures:
https://deg.nc.gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-
regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
https://edocs.deg.nc.gov/WasteManagement/Search.aspx
Document Submittal & UST File Names for Laserfiche Policies:
https://files.nc.gov/ncdeq/Waste%20Management/DWM/UST/Corrective%20Action/Electronic%20Doc
ument%20Submittal%20Memo%20Update. pdf
https://files.nc. gov/ncdeq/Waste%20Management/D WM/UST/Corrective%20Action/UST%20file%20na
mes%20f6r%20Laserfiche.docx
From: Newton, Brad
Sent: Friday, December 14, 2018 12:36 PM
To: Beverly, Trudy <[e-mail]>
Subject: FW: [External] sysco, concord
<image009.png>
Branch's Underground Storage Tanks Website Address: https://deg.nc.gov/about/divisions/waste-
management/ust
Branch's Above Ground Storage Tanks Website Address: https://deg.nc.gov/about/divisions/waste-
management/ust/ast-program

INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
https://deg.nc.gov/about/divisions/waste-management/waste-management-rules-data/waste-
management-gis-maps
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):
https://edocs.deg.nc.gov/WasteManagement/Search.aspx
Document Submittal & UST File Names for Laserfiche Policies:
https://files.nc.gov/ncdeq/Waste%20Management/DWM/UST/Corrective%2OAction/Electronic%2ODoc
ument%20Submittal%2OMemo%2OUpdate.pdf
https://files.nc. gov/ncdeq/Waste%20Management/DWM/UST/Corrective%2OAction/UST%2Ofile%20na
mes%20f6r%20Laserfiche.docx
From: Corey Buchanan<[e-mail]>
Sent: Friday, December 14, 2018 12:34 PM
To: Newton, Brad <brad.newton @ncdenr.gov>
Subject: [External] sysco, concord
External email. Do not click links or open attachments unless verified. Send all suspicious email as and
iant to: - .. iar.l
Hello Brad,
Iam working with Sysco on the Sysco concord site. We did a site check at the site and they had a
hot soil sample/ust release, so this will require a LSA to confirm water contamination.
Are you the IM working on this project? If I propose one well install and soil sampling during
well install and receptor survey that should take care of this LSA to start with right?
Just want to confirm before I put together a proposal for the LSA for them.
Let me know if that works, thanks
Best Regards,
Corey N. Buchanan, P.G.
Project Manager
Geological Resources, Inc.
3502 Hayes Road
Monroe, NC 28110
Main [phone] Cell [phone] Fax [phone]
www.geologicalresourcesinc.com
NCPCM 2015 Vendor of the Year Recipient
Business North Carolina Magazine 2015 Small Business of the Year Runner-up Recipient

Beverly, Trudy
From: Beverly, Trudy
Sent: Friday, December 14, 2018 8:04 AM
To: Bowser, Daniel P
Subject: RE: [External] UST-61 form for the Sysco site located at 4500 Corporate Drive NW in
Concord, NC
Thanks!
Trudy
O-E Q �11)
ogcw~ *I E■.vcury
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
North Carolina Department of Environment Quality
Underground Storage Tanks Section
Corrective Action Branch
Mooresville Regional Office
[phone] (Office)
Trudv.Beve rlvCa)ncdenr.Rov
Ernad CcfreSpomLar B to aid from this adcfre 5 rs �5ubjGc:t to ttae
h C'ai-cVm Pubic -ReccOs Law aW m?v Ne, dwOsed b third part.
Branch's Underground Storage Tanks Website Address: https://deg.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: https://deg.nc.gov/about/divisions/waste-
management/ust/ast-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
https://deg.nc.gov/about/divisions/waste-management/waste-management-rules-data/waste-management-gis-maps
File Review Procedures:
https://deg.nc.gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
https://edocs.deg.nc.gov/WasteManagement/Search.aspx
Document Submittal & UST File Names for Laserfiche Policies:
https://files.nc.gov/ncdeq/Waste%20Management/DWM/UST/Corrective%2OAction/Electronic%2ODocument%2OSubmi
ttal%20Memo%2OUpdate.pdf
https://files.nc.gov/ncdeq/Waste%20Management/DWM[UST/Corrective%2OAction/UST°/`2Ofile°/`20names%20for°/`20
Laserfiche.docx
From: Bowser, Daniel P
Sent: Thursday, December 13, 2018 10:44 AM
To: Beverly, Trudy <[e-mail]>
Subject: Fwd: [External] UST-61 form for the Sysco site located at 4500 Corporate Drive NW in Concord, NC
This is in Concord. Sent to me by accident
Dan Bowser, PG
NCDEQ

UST Section
Corrective Action Branch
From: Taraban, Ron <[e-mail]>
Sent: Thursday, December 13, 2018 10:14 AM
To: Stutts, Jack L
Cc: Bowser, Daniel P
Subject: FW: [External] UST-61 form for the Sysco site located at 4500 Corporate Drive NW in Concord, NC
This just came in.
thanks
From: Corey Buchanan<[e-mail]>
Sent: Monday, December 10, 2018 2:24 PM
To: Taraban, Ron <[e-mail]>
Subject: [External] UST-61 form for the Sysco site located at 4500 Corporate Drive NW in Concord, NC
., , • External email. Do not click links or open attachments unless verified. Send all suspicious email as an attachment to : o
Hello Mr. Taraban,
Please find attached the UST-61 form for the Sysco site located at 4500 Corporate Drive NW in Concord, NC
was out of town and I don't think this was sent in before the site check report was completed.
Let me know if you have any question, thank you.
Best Regards,
Corey N. Buchanan, P.G.
Project Manager
Geological Resources, Inc.
3502 Hayes Road
Monroe, NC 28110
Main [phone] Cell [phone] Fax [phone]
www.geologicalresourcesinc.com
NCPCM 2015 Vendor of the Year Recipient

Business North Carolina Magazine 2015 Small Business of the Year Runner-up Recipient