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HomeMy WebLinkAboutMO-9412_40858_G_C_20181024_Geological Resources Emails Testing ViolationsBeverly, Trudy From: Lisa Hilbish<Ilh@geologicalresourcesinc.com> Sent: Wednesday, October 24, 2018 11:21 AM To: Beverly, Trudy Subject: Re: [External] FW: Sysco Charlotte - Corrective Action(s) for Response to Notice of Violation Thank you. I have the guidelines. I was just confirming because in one of the emails the client sent it looks like Jack Stutts recommenced getting confirmation from the Mooresville office. Sent from my iPhone On Oct 24, 2018, at 10:09 AM, Beverly, Trudy <trudy.beverly@ncdenr.gov> wrote: Hi Lisa, The UST Site Check Guidelines for Regulated UST Systems can be found in Section 4 of the Guidelines for Site Checks, Tank Closure and Initial Response (text and figures) 1/9/2018 on the UST website (Pages 5- 8). Soil sampling requirements can be found in Section 4.3 Site Check Requirements (Page 6). The tables and appendices can also be found at the link below (separate from the text document). httr)s://dea.nc.gov/about/divisions/waste-management/ust/guidance-documents Have a wonderful day! Trudy <image002.png><i mage003.jpg> <image004.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: httr)s://files.nc.Rov/ncdea/Waste/20Manaaement/DWM/UST/Corrective%20Action/Electronic%20Doc ument%20Submittal%20Memo%20UPdate.pdf https://files.nc.izov/ncdea/Waste%20ManaL-ement/DWM/UST/Corrective%20Action/UST%20file%20na mes%20f6r%20Laserfiche.docx From: Taraban, Ron Sent: Wednesday, October 24, 2018 9:38 AM To: Beverly, Trudy <trudy.beverly@ncdenr.gov> Subject: FW: [External] FW: Sysco Charlotte - Corrective Action(s) for Response to Notice of Violation From: Lisa Hilbish<Ilh@geologicalresourcesinc.com> Sent: Tuesday, October 23, 2018 8:25 AM To: Taraban, Ron <ron.taraban@ncdenr.gov> Subject: [External] FW: Sysco Charlotte - Corrective Action(s) for Response to Notice of Violation attachment L- Hi Ron, Can you tell me who handles Cabarrus county? We have been contacted by Sysco for assistance with a site check. We understand from the documentation given to us that 3 samples need to be taken — one at each dispenser sump and one at the STP sump. I wanted to confirm with this with whomever handles Cabarrus county. Thanks. Best Regards, Lisa Hilbish Senior Business Development Director Geological Resources, Inc. 3502 Hayes Road Monroe, NC 28110 Main (704) 845-4010 Cell (704) 236-1120 Fax (704) 845-4012 www.geologicalresourcesinc.com From: Callahan, Josh R. 048 [mailto: CaIlahan.Joshua@cha.sysco.com] Sent: Monday, October 22, 2018 5:14 PM To: Lisa Hilbish Subject: RE: [External] Sysco Charlotte - Corrective Action(s) for Response to Notice of Violation Thanks for confirming. The UST 23B is in the Violation 6 attachment. From: Lisa Hilbish [mailto:llh@geological resourcesinc.com] Sent: Monday, October 22, 2018 4:57 PM To: Callahan, Josh R. 048 <Callahan.Joshua@cha.sysco.com> Subject: RE: [External] Sysco Charlotte - Corrective Action(s) for Response to Notice of Violation [ External Email ] Thank you — I have everything. Can you confirm that you have made all the repairs and if so can you send me the documentation (the UST 23B form). Best Regards, Lisa Hilbish Senior Business Development Director Geological Resources, Inc. 3502 Hayes Road Monroe, NC 28110 Main (704) 845-4010 Cell (704) 236-1120 Fax (704) 845-4012 www.geologicalresourcesinc.com From: Callahan, Josh R. 048[mailto:Callahan.JoshuaCacha.sysco.com] Sent: Monday, October 22, 2018 3:59 PM To: Lisa Hilbish Subject: FW: [External] Sysco Charlotte - Corrective Action(s) for Response to Notice of Violation Importance: High From: Thomas, Robert 1001 Sent: Monday, October 22, 2018 1:20 PM To: Stillwell, Tim 048 <Stillwell.Timothy@cha.sysco.com>; Callahan, Josh R. 048 <Callahan.Joshua@cha.sysco.com>; McIntyre, John 048 <Mclntyre.John@cha.sysco.com> Cc: Wills, Corinna 000 <Wills.Corinna@corp.sysco.com>; Flynn, Barrett 000 <Flynn.Barrett@corp.sysco.com> Subject: FW: [External] Sysco Charlotte - Corrective Action(s) for Response to Notice of Violation Importance: High Tim, Per our conversation this morning, attached is the Inspectors response to Sysco Charlotte submittal, as well as, his email below (see highlighted comment by Inspector for your consultant). Specifically, Violation 4 of the referenced NOV states that "if any containment sump fails the tightness test you must conduct a site check in accordance with 40 CFR 280.52(b)". Accordingly, both the dispenser sumps and the STP sump of the diesel UST failed their tightness tests prior to their repair. Therefore, Sysco Charlotte must complete the appropriate site checks using the sampling protocol and methodology of the UST Section Guidelines for Site Checks, Tank Closure, and Initial Response and Abatement. Sysco Charlotte response for Violation 4 is due within 30 days of the attached letter (November 18") Per our conversation, Jones & Frank or another vendor should re -conduct the tightness test for both the dispenser sumps and the STP sump, as well as, complete UST-6F/23B Forms on behalf of Sysco Charlotte. As you stated, you'll discuss this matter with your team and have the appropriate consult onsite to rectify this matter with Violation 4. Let's discuss this matter further. Regards, Robert D.F. Thomas Director, Environmental Compliance Sysco Corporation Thomas.Robert2kcorp. sysco. com O: 281.584.5045 C: 832.457.8900 From: Stutts, Jack L [mailto:iack.stutts@ncdenr.Rov] Sent: Monday, October 22, 2018 11:24 AM To: Thomas, Robert 1001 <Thomas.Robert2@corp.sysco.com> Cc: Callahan, Josh R. 048<CaIlahan.Joshua@cha.sysco.com>; Stillwell, Tim 048 <Stillwell.Timothy@cha.sysco.com> Subject: RE: [External] Sysco Charlotte - Corrective Action(s) for Response to Notice of Violation [ External Email ] Robert, Thank you for the electronic submission. Attached is my response to the information. As you will see in the letter, there is a requirement for Sysco to perform a site check or checks because of the failure of the initial tightness test of the STP sump and the dispenser sumps. Your consultant should contact the Corrective Action Branch Regional Office in Mooresville if they need assistance is determining the appropriate location(s) and number of sample(s) they will require. Feel free to contact me with any questions or if you find Sysco needs more than the allotted 30 days to complete the site check. Jack From: Thomas, Robert 1001[mailto:Thomas.Robert2@corp.sysco.com] Sent: Wednesday, October 3, 2018 2:48 PM To: Stutts, Jack L <iack.stutts@ncdenr.gov> Cc: Callahan, Josh R. 048<Callahan.Joshua@cha.sysco.com>; Stillwell, Tim 048 <Stillwell.Timothy@cha.sysco.com> Subject: [External] Sysco Charlotte - Corrective Action(s) for Response to Notice of Violation External email. Do not click links or open attachments unless verified. Send all suspicious email as an I attachment to Hello Jack, Per our last correspondence, on behalf of Sysco Charlotte attached for your review are the corrective measures implemented to ensure regulatory compliance with each Notice of Violation (NOV). In addition to each corrective measure, we've also included the final invoice from our vendor Jones & Frank that displays (1) every service date; (2) the item/description for each equipment serviced; and (3) the final expenditure for all work performed at the cost of $24, 990.27. If you have specific and/or technical inquiries regarding the corrective measures in question, please give Josh Callahan a call at 704-723-6067 or contact him via email at Callahan.Joshua@cha.sysco.com . Thank you for your attention with this matter. Best Regards, Robert D.F. Thomas Director, Environmental Compliance Sysco Corporation Thomas.Robert2(cr�,corp. sysco.com O: 281.584.5045 C: 832.457.8900 Violation. Z: 15A NCAC 2N .05D2 LD.1 Application to Install olr.Replace Underground Storage Tank Systems USTwfiE123D (TANK 1NSTALLATIONR.RIENNIAL TESTING) A A separate farm should ae used for each facility. If there are more than five (5) tanks at this faoility, make addjttanel copies df us. page. written guldelines and PEURP.100 "Recommended Practice. Y. The primary and. Interstitial space of the tank shall be tested In accordance with the marlufactureis for Installation of Underground Liquid Storage -Systems: ra The last periodic tightness:test record must be maintalned by the tank owner or operators nd must.be readily available for inspection. Tanks that are not manitored.com]nuvusly for releases using vacuum, pressure, or. hydrostatic methods. must be rightness tested at.Installation, between 6 and I months from: lnstallation,:and.every thres years faliowing.installatibn. The interstitlatspace of the tank shall bo tested using.a 3. ro party certified Interstice tightness test capable of detecting a 0.1 gpll teak from the inner or outer wail of tha interstice for the tank model that is Installed. s If tha.tank faits a tightness test; it must ice replaced or repaired. by the man ufactureror.the manufacturer's authorized representative in accordance with the . manufacturer's socN�cations: Following.any repair, the flank must be re -tested for tfghtness.Also a suspected release report: must be submitted on a USTA 7A form, tISTSuspecfed Refease.24 NourNolfce. The suspected release must be:€nvestigated, In accordance with 15A NC.AC 2N .0503, and any defective equipment repairedlreplaced In accordance: with i5A NCAC 2N..04041,0900. Resutlsof the investigation must be submitted on A USTA 78. form,. UST Suspected Release 7 Day Notice. ACILITY Owner 1 Fac. Name Fac. ID#; 00-0-0000035443 Operator Name Fac. Address Fac. City unty CA6ARRLiS 450o CORPORATE DRIVE; NW CONCORD o. Name Phone -mail Superior Services 828=698=6286 daveb@superiorservices.us Address city rate zip P.O. Box 982 Hendersonville NC .28793 Kelly Keller WA t Print Name. 7 person conducting test Signature of person conducting test. Identify Tank (Tank Number, etc.) Tank # 1 Tank # Tank# Tank # Tank # Tank Size 20000 Product Diesel uST Type FRP US7'. es: FRP+ Steel Jacketed, 5tee11CLAD,.Dth,9r Indicate units for all measurements: inches I. Pre-frrstallatlon testing VacuumMressure Gauge Ran w Test Date Interstitial space =Liquid Filled or Vacuum. ITestmethod. Vacuum Liquid filledlather: begin EndTest Time (liquid} Begin. End.Level(liquid) r 1 1 r r I 1 Begin End Test Time Begin End Pressure/Vacuum 1 E r I I 1 1 1 Test Result El Pass EFal€ Pass Fall Pass Fail Pass Fall Pass Faii Liquicivisibis on insldelauteide. Yes ❑Ida Yes No Yes No Yes No Yes No of tank(If applicable) It. Post-instaMllonitriertnialAesting Tightness Test Mode (if applicable): Test. Date, Begin .End . ' 0312V2018 r 03124120t8 ' i r i i F Interstitial space -Liquid Fif c1lother. Teat method: QVacuum Liquid fitledlother: Xerxes Begin .End Test Time (liquid) 11:33 21:33 Begin End Level (liquid) 12.15 ; 12.75 i Begin End Test Time: r I 1 r Begin End Pressure/Vacuum Test Result Pass MFail Pass Fail Pass Fail Pass Fail Pass Fail Llquidvlsible on. Inside of tank joyes NNo I Yes No Yes No Yes No Yes No NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION 10115. 1646 MAIL sERViCI; CENTER, RALEIGH, NO 27696-16.46. PHONE (619) 70741.71 FA)C (919) 716A 117bttp:/Avww.wastenotnc.orghveblwm Recommended. Practices for the Testing and Ver tcatlon of So11, Overfill, Leak Detection and Secondary Containment Equipmerft at. UST Fatalities ZCU I XERXES making a lasting difference DIATA LOG TRUCHEK' Fill out the site location, tank information and test boxes below..Be sure to [noose the carrerl test box according to the diameter. of the'tank being tested. Follow t)he test procedures on the. other side of this form. A.sepa►ate test form is needed for every tank. Fpr additional cap ies.of the form, contact the Customer Service Representative at the.Xerxes manufacturing facility nearest you. (See back cover for information.) Site Location: Sysco Food services. of Charlotte Tank Information: Address: 4500 Corporate Drive. NVV Nominal Gallons: LO 09 Concord,. NC Diameter: 120" Phone: 704-723-6067 Contact Name: Josh Callahan. Test Date: 3-24-2018 95%-S%TEST 1 a. Start level (inthes in standpipe) 2a. End Level after 4 hours 3. D&rem .tsubtract 2a from I a) — 4. Calbration factor - z .20 S. Volume change = 6. Test hours + 4 7.:Gallops-per`hour loss — (if 0..05 gal bnAaw or. less, tank passed.). Nate: maximurn allowable dispensing volume during test: B-foot-diamete► tarok--1.200 gallons maximum 6-foot diameter.tank — 500 gallons maximum 4-foot•diamew rank — 3W gal Ions:rnaximum 95% - 5% TEST 10. Stare level (inches in standpipe) 2a. End level after 6 hours - 3, Difference Witract2a from i a) _ 4. Calibration factor x. .30 S. Volume change — C Test hours + 6 T. Gallons-pervhour lass — (if 0.05 gallonslhour or less, tank passed.) Note: Mauknurn allowable. dispensing .volume during test; 10-foot-diameter tank -� 75U gallons: maximum Approximate. Standpipe Length: 39-25" Product Type: 17iesel Person Performing Test' Kelly Keller - Superior Services C. 999ts -1 % TEST 1b. Start level (indi s in standpipe) .2b. End level after.I D hours 3. Difference (subpar# 2b from I b) 4. Calbation factor 5. Volume change 6. Test hours 7. Gallons -per -hour loss (if 0.05 gal.lorslhour or less, tank.passsd:) Note: No product. dispensing allowed. 99W-1 % TEST 1b. Start level (inches in standpipe) 2b. End level after 10 hours 3: Difference (subtract:20:frartr 1 b) 4, Calibration factor S..Vokrme change 5, .Test hours T Gallons -per -hour loss (if 0.05 gallons]hour or less, tank passecl,) Note: No. product ftpensing allowed. x .20 + 10 12.75" OZ x 10. OA GPH + 10 = 0.0 GPH pei:nrg TIORI'VIL JS.: D T.L4P L I CENSOR M)Rr Itq. END 4 L I 'D:1022L E;FhOOP fV;Pp,j,:,L r7 * > » * 4, mjri -; - , ' w Vioiatlon 3: 15A NCAC 2N .0505 R:CD5 UST-6H/23C Triennial UST Piping Integrity Testing (for components installed on or after* 11/112007 or when returning any LIST system to service from temporary closure) " This form must be used to document pipe integrity testing (far piping not monitored continuously for releases using vacuum, pressure, or hydrostatic methods) for UST systems installed an or after November 1, 2007 (this includes existing UST systems that have installed or replaced the piping on or after November 1, 2007) or For any existing UST system conducting interstitial monitoring of the piping regardless of installation elate prior to returning to service from temporary closure. If there are more than five (5) piping systems at this facility, make additional copies of this page. r The primary containment and interstitial space of the piping shall be tested in accordance with the manufacturers written guidelines and PEIIRP100 "Recommended Practice for Installabon of Underground Liquid Storage Systems." The last periodic tightness test record must be maintained by the tank owner/operators and must be readily available for inspection. If any periodic test fails, a suspected release report must be submitted an a UST-17A form, UST Suspected Release 24 Hour Notice, and investigated in accordance with 15A NCAC 2N .D603, and any defective equipment repaired in accordance with 15A NCAC 2N .04041.0900. Results of the investigation must be submitted on a UST- 17B form, UST Suspected Release 7 pay NoWe. If the piping fails a tightness test, it must be replaced or repaired by the manufacturer a the manufacturer's authorized representative in accordance with the manufacturer's specifications. Foilovving any repair, the piping must be re -tested for tightness. LIST FACILITY 5ysco 6701 Northpark Blvd Charlatte NC �tato 282 16 1 certify, under penatty or taw, that the testing data provided on this form documents the FIST system equipment was tested in 9Wordanoe vAh the manufacturer's guidelines and the applicable national industry standards listed In 15A NCAC 2N Opoo Shawn Bernas f: Print Name of person conducting test fgnature of person conducting test Identify piping system (By Tank # Tank # Tank � Tank Number, Stored STP line 1 5TP line 2 Satalite 1 Tank # # Satalite Tank Product etc. Tank Sire 20K 20K Z0 K 20K Product diesel On Road Diesel On road Diesel On Road Diesel Can Road Piping Type(DW FRP, D!►V DW Flex DW flex ❑W Flex Flex, Other DW Flex ❑ Gravity ❑ Gravity ❑ Gravity E3 Gravity ❑ Gravity Piping Configuration ❑ Manifold ❑ Manifold ❑ Manifold ❑ Manifold ❑ Manifold 0 Pressurized 0 Pressurized 0 Pressurized © Pressurized ❑ Pressurized 171 Suction D Suction Suction Suction Suction Piping Manufacturer I APT X gen 2 APT XP gen 2 APT XP gen 2 APT XP gen 2 Pipe Model (Part No.] Indicate Test Phase: ■ Triennial Testing Post -Installation Return to Service from Tem ra Closure Test Date 6/1/2018 6I112018 6111201 B 6/1/2018 A. Primary Pipe Test (Note: Must be a third -pally certified tightness test) (Attach test data sheets to form) Lino Tightness Test Results Attached Yes No ❑Yes 0 No Yes No El IVa ❑Yes ❑ No B. Secondary Interstice Test (Indicate units for all measurements) BeginiEnd test time 1200 1300 1415 143U 1530 1545 1645 11315 Begin i End pressure i❑ Psi 110 Psi 10 Psi W Psi 10 Psi 10 Psi 10psi 10 Psi Secondary Test Result Q Pass ❑ Fail � Pass ❑ Fail [e] Pass ❑ Fail e❑ Pass ❑ Fail ❑ Pass ❑ Fail Comments and explanation of railing results and other problems noted firing inspection Double wail testing boots were deemed bad by Superior Testing Co, Testable boots were replaced and adjusted and tested ok. NORTH CAROLINA DEPARTMENT OF ENVIRONMr=NTAL QUALITY, DIVISION OF WASTE MANAGEMENT. LIST SECTION 1646 MA)L SERVICE CENTER, RALEIGH, NC 27eW-1640 PH0NC (919) 70T-81_t1 FAX (919)715-1117 htlPJMWw wastenotncorghveblwm 1b115 A lication to...Initall ar Re lace Underground Storage. Tank S stems Pp P Y. UST,6E/23D {TANK INS fALli4`fI6 &OIEWAL:TESTIHG 0 A separate form should be used for each faciiity..if there are more than five. (5) tanks at this facility. make. additional copies of this page. `Recommended 0 The primary and Interstitial space of the tank shall be tested in accordance with theme nufacturerswdttan guidelines and PEIlRP100 Prachos for lnstallalion of Underground Liquid Storage Systems." 0 The last periodic tightness test record must be maintained by the tank owner or operatorand must. be readily available for inspection,. • Tanks that are not monitored con tinuously .for releases using vacuum, pressure, or. hydrostatic:methods .must.be tightness tested at installatlon, between 6 and 12 months from installation, and every three years fallowing installation. • The Interstitial space of the tank shall be tested.using a 3: ro party ckfied interstice tightness test capable of detecting a 0.1 gph leak from the:,inner:or outer Well of the:interstice:for the tank model that. Is: installed. r If the tank fails a tightness. test, it must be replaced: or repaired by the manufacturer or She. manufacturees.authorized representative in accordance with the manufac(urets specifications. Following any repair, the tank must be retested for tightness.Also a suspected release report must besuhmitted an a UST-17A form,. UST Suspected Release 24 Mour Notice.. The suspected release' must be investigated; inaccdrdahoe with 15A:NCAC 2N .0603,. and .any defective equipment repairedirepiaced in accordance.with 15.A NCAC 2N .04041M00. Results of the investigation mustbei submitted on a UST=17B #orfn. UST Suspected Release 7 Day NolieaUST FACILI Owner l Fac: Name Fac. ID#: 00-0-0000035"3 Operator Name Fac. Address. Fac. City County. bRIVE, CONCORD CABARRUS. 4500 CORPORATE NW Co. Name Phone -mail Superior Services 828-698-6286 dave a@superiarservices.us Address P.Q. Box 982 City Hendersonville State PVC Zip 28793 Kelly Keller Signature of person conducting test Print Name of person canducting lest Identify Tank {Tank Numbar, etc.) Tank # Tank # Tank # Tank.#: Tank # Tank Size 217ia00 Diesel Product UST Type FRP US7 pes`:FRp, Steel.JacikoW,, SteeblQLAD,.Otlier. Indicate units for all measurements: inches 1.:PreAnstallation:testln9 Vacuum/Pressure Gauge Range: Test Date. interstitial :space -Liquid Fillet! cr Vacuum. ITest method: Vacuum Liquid filledlother: Begin EndTest Time (liquid) Begin End Level(liquid) '. I Begin End. Test Time: Begin End Pressure/Vacuum Yost Resent Pass Fail Pass Fail Pass Fail Pass Fail. Pass Fail Liquidvisible on Insideloutside Yes [:]No Yes No Yes No Yes No Yes No of tank(If applicablej. II. PoWnstailationitriennial testing Tightness Test Modell (if applicable.)'. Test Date: Begin End i 63124121118 03124f2018 Interstitial:space.Liquid: Fllled[Other; Test method: Vacuum .� Liquid filfedlvther: Xerxes. Begin End Test Tlme (liquid) 11:33 21:33 e Begin End Level (liquid) 1.2.75 12.7.5 P ; ' Begin End Test Tlme r i Begin End Pressure/Vacuum Test Result Pass FjFall Pass Fall Pass Fall Pass Fail Pass Fail Liquidvisible: on inside -of tank Yes KNO Yes No Yes Na. Yes No Yes. No ENV! RONuENTAL.CJALITY..WMANAGEMENT NORTH C:ARQLINA 7EARTMENT .- .M C01 15 .7F. 1fi46MPiL SERVIGE'CEVTERE�A1 i=fPH, NC..27699.-16 PHQNE%{g19j'74T 8171 FA7C t919] 715-11 17 http:IlwaVw.wasterioi�le.orglweblwm '. .: Recommended Practices for the Testing and Verification of Spill, OVeill, Leak Detection and Secondary Containment Equipment at UST Facilities U I XERXES` making a lasting difference TRUCHEKDATA LOG Fill out the site location, tank information and test boxes below. Be sure to choose the correct test box according to the diameter of the tank being tested. Follow the test procedures on the other side of this farm. A separate test form is needed for every tank. For additional copies of the form, contact the Customer Service Representative at the Xerxes manufacturing facility nearest you. (See back cover for information,) SITE LOCATION • ■ TANK INFORMATION Site Location: Sysco Food Services of Charlotte Address: 4500 Corporate Drive, NVV Concord, NC Phone: 704-723-6067 Contact Name: Josh Callahan Test Date: 3-24-201 B 95% - 5% TEST 1 a. Start level (inches in standpipe) 2a. End level after 4 hours 3. Difference (subtract 2a from 1 a) - 4. Calibration factor x .20 5. Volume change - 6. Test hours + 4 7. Gallons -per -hour loss = (If 0.05 ga]Ion slhour or less, tank passed.) Note: maximum allowable dispensing volume during test: 8-foot-diameter tank - 1,200 gallons maximum 6-foot•diameter tank -- 500 gallons maximum 4-foot-diameter tank - 30D gal Ions maximum 95% - 5% TEST 1 a. Start ievet (inches in standpipe) 2a. End level after 6 hours 3, Difference (subtract 2a from 1 a) - 4. Calloration factor x .30 5. Volume change = 6. Test hours 6 7, Gallons -per -hour loss = (If 0.05 gallonsihour or less, tank passed.) Note: Maximum allowable dispensing volume during test: 1D- foot -di ameter tank - 75D gallons maximum Tank Information: Nominal Gallons: 20000 ❑ia meter:120" Approximate Standpipe Length: 39.25" Product Type: Diesel Person Performing Test: Kelly Keller - Superior Services C 99% - 1 % TEST 1 b. Start level (inches in standpipe) 2b. End level after 1 D hours 3. Difference (subtract 2b from 1 b) - 4, Calibration factor x .20 5. Volume change = 6. Test hours + 10 7. Gallons -per -hour loss - (If 0-DS gal Ion ski our or less, tank passed,) Note. No product dispensing allowed. 99% - 1% TEST 1 b, Start level (inches in standpipe) 12.75" 2b. End level after 10 hours 1215" 3. Difference (subtract 2b from 1b) = 0A1 4. Calibration factor x .30 S. Volume change = 0.0 GPH 6. Test hours + 10 7. Gallons -per -hour toss = 0.0 GPH (If 0.05 gallonsMour or less, tank passed.) Note: No product dispensing allowed. pei.arg 0 it. 12 L I D. I FS'E'L C3 Ci .4 s F- F L SO%8op END Violation 4: 15A NCAC 2N ..0GU3RLS5 USTA 76 UST Suspected Release 7 Day Notice queen This form must be used to report to DEQ, within 7 days of discovery, the investigation results for 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 "Increase", which indicates 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; the unexplained presence of water 1n the tank; the presence of fuei in containment sumps or interstitial spaces; or the degradation of any equipment or element of an underground storage tank system to the point where that equipment or element can not reasonably be expected to perform its intended function. c) Internal inspection results such as, perforations, corrosion holes, weld failures, or other similar defects that indicate a release could have occurred. If you have more than four UST systems to report suspected release investigations, then attach additional sheets of the UST-17B form. Please submit this form along with the supporting documentation to: NCDEQIDWM, UST Section 1646 Mail Service Center Raleigh, North Carolina 27699-1646 OR Fax to (919) 715-1117 OR UST.Permits ncdenr. ov I. UST OWNER II. UST FACILITY Name: Name: Facility ID: Sysco Charlotte LLC Sysco Charlotte LLC 00-0-0000035443 Address: Address: 4500 Corporate Drive NW 4500 Corporate Drive NW City: State: Zip: City: County. - Concord NC 28027 Concord Cabarrus Person Reporting: Title of Person Reporting: Telephone Number: Josh Callahan Fleet Manager (704) 723-6067 III. INVESTIGATION RESULTS Tank Number 1 Size: I 1 ! 20,000 Gal 1 1 1 Product Stored: Reason for Suspected Release Investigation (Check all that apply): You must attach the supporting documentation specified in the footnote for the reason(s) selected. Diesel ❑ Data entry error' ❑ Dispensing fuel while test is being conducted ® Faulty equipment' ❑ Incorrect stick or meter reading' ❑ Incorrect tank chart { ❑ Internal Inspection' ❑ Meter not calibrated c ❑ Other (Attach explanation)' ® Tank/Dispenser containment sump contains liquid' ❑ Tilted tank ° ❑ Unknown' ❑ Data entry error' ❑ Dispensing fuel while test is being conducted t ❑ Faulty equipment 3 ❑ Incorrect stick or meter reading' ❑ Incorrect tank chart' ❑ Internal Inspection s ❑ Meter not calibrated s ❑ Other (Attach explanation)' ❑ Tank/Dispenser containment sump contains liquid' ❑ Tilted tank" ❑ Unknown' ❑ Data entry error' ❑ Dispensing fuel while test is being conducted 2 ❑ Faulty equipment 8 ❑ Incorrect stick or meter reading' ❑ Incorrect tank chart ° ❑ Internal Inspection 5 ❑ Meter not calibrated e ❑ Other (Attach explanation)' ❑ Tank/Dispenser containment sump contains liquid' ❑ Tilted tank $ ❑ Unknown' ❑ Data entry error' ❑ Dispensing fuel while test is being conducted P ❑ Faulty equipment' ❑ Incorrect stick or meter reading' ❑ Incorrect tank chart 4 ❑ Internal inspection 5 ❑ Meter not calibrated $ ❑ Other (Attach explanation)' ❑ Tank/Dispenser containment sump contains liquid 7 ❑ Tilted tank ° ❑ Unknown' Conduct a tank and/or line tightness test and attach the results, along with all of the supporting data sheets for the test method, to this form for submittal. The summary page listing the results by itself is not acceptable. If the tightness test results are fail, then you must repair or replace your UST system and conduct a site check in accordance with 15A NCAC 2N .0603. s Provide sales receipts or other comparable documentation that shows fuel was being dispensed from the UST during the test. ' Provide invoices (with a description of the work completed) or other documentation that shows the equipment has been repaired. 4 Correct your leak detection results using the correct tank chart and submit copies with this form. s Repair the UST in accordance with the manufacturer's instructions or a national standard (e.g., PEI API 1631) and conduct a site check in accordance with 15A NCAC 2N .0601 If the UST is not repaired, then it must be permanently closed in accordance with the latest version of the UST Sections Guidelines for Tank Closure. ° Correct your leak detection results using the amount your meter was adjusted following calibration and submit copies of the meter calibration and leak detection results with this form. 7 Conduct a tightness test (e.g., hydrostatic test) of the sump and submit the test result along with this form. If the test results are fail, then you must repair or replace the containment sump and conduct a site check in accordance with 15A NCAC 2N .0603. s Submit documentation from your UST equipment contractor explaining how they determined the UST was tilted. Correct your Peak detection results using a tank chart adjusted for the tilt and submit with this form. Note: Tank, piping, spill bucket and containment sump replacements must be done in accordance with 15A NCAC 2N .0900 UST-17B Revised 1012015 http:llwww.wastenotne.org/web/wm/ Triennia! UST Containment Sump 1 UST-fiF123B UDC Integrity Testing . 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 Results of the investigation must be submitted on a UST- 17B form, UST Suspected Release 7 Day Notice. .0404L0900, • Containment sumps installed on or after 111112007 that are not monitored cortinuousty for releases using vacuum. pressure, or hydrostatic interstitial monitoring methods and all other containment sumps Installed prior to 111112D07 that are used for interstitial monitoring shall be tightness tested at installation and every three j3) years thereafter in amordancc with the manufacturer's written guidelines, PEURP100'Recommend ad Practices far Installation of Underground Liquid Storage systems" andlor PEllRP1200 "Recommended Practices far the Testing and Verifieatian of Spill, Overfill, Leak Detection and Secondary Containment Equipment at UST Facilities." • If a UDC 1 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 wtth the manufacturer's speciflcatlars. UST FACILITY Owner 1 Operator Name Facility Name Facility ID Sysco Sygco 0040-0D0035443 Facility Street Address Facility City County 45M Corporate Drive Concord Cabarrus CONTRACTOR/PERSON CONDUCTING INSPECTIONS Company Name Phone Email address Jones -Frank 7114 39343542 Shernas@jones4rank.com 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 manufacturers guidelines and the applicable national industry standards listed in 'I5A NCAC 2N .406 andlor 15A NCAC 2N .0900, Shawn Bernas Signature of p on conducting inspection 5110f2018 Print Name of person conducting inspection Inspection Date Identify UDC/sump (By ❑ Dispenser ❑ Dispenser ❑ Dispenser ❑ Dispenser ❑ Dispenser ❑ Dispenser Dispenser No. or Tank Number, ® Tank # © Tank # ❑ Tank. # ❑ Tank # ❑ Tank # ❑ Tank # Tank Size, Storsd Producte.g. #1 10k Ragular STP, Disp 112, #, Diesel 20K # # # # # etc.) Transition sumps should he listed alcove as "TS-XX" (with XX= sump II34) Sump Manufacturer Xerxes ® FRP ❑ FRP ❑ FRP ❑ FRP ❑ FRP ❑ FRP bump Material ❑ Plastic ❑ Plastic ❑ Plastic ❑ Plastic ❑ Plastic ❑ Plastic ® Single Wall ❑ Single Wall ❑ Single Wall ❑ Single Wall ❑ Single Wag ❑ Single Wall Sump Type ❑ Double Wall ❑ Double Wall ❑ Double Wail ❑ Double Wall ❑ Double Wall ❑ Double Wall Hydrostatic ❑ Hydrostatic] Hydrostatic ElHydrostatic ❑ Hydrostatic ❑ Hydrostatic Test Type ❑ Vacuum © Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum Indicate units for ail measurements Liquid and debris removed from ® Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No sump? Visual inspection (No cracks, loose parts or separation of the ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail containment sump) Sump Depth 46 Height from sump bottom to top of highest penetration or sump 19.5 Inch sldewall seam Waft time between applying 15 mins vacuum/water and start of test Begin i End Test Time 1 PM 2 PM (minimum test time. 1 hour) Begin I End values 21.5 Inch 21.5 Inch Pass)Fait criteria: Must pass visual Inspection, Hydrostatitr_ Water level drop of less than 118 inch; Vacuum: No change in vacuum Test Results ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail I © Pass ❑ Fall 10 Pass ❑ Fall ❑ Pass ❑ Fall Comments and explanation of Tailing results and other problems noted during inspection: Site Failed hydrostatic, we replaced all boots in STP sump and all tested ok. Date next Containment Sump/UDC integrity test due (required every 3 years) 5109/2021 NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION 512017 1646 MAIL SERVICE CENTER. RALEIGH, NC 27699-1646 PHONE (919) 707-8171 FAX (919) 716-1117 hltpJAy.m .wastenotnc Qro! Remit To: Junes & Frank PO Box 531829 ATLANTA. GA 30353-1829 919-838-7555 RILL CUST-0001993 TO: SYSCO 4500 CORP DR Concord, NC 28027 SERVICE INVOICE:PSER-0349908 SHIP: CUST-0001993 TO: SYSCO 4500 CORP DR Concord, NC 28027 Page: 1 INVOICEDATE CUSTOMER/ PAYMENTTERMS CALLER NAME 12/21/2017 Josh Callahan Net 30 Days Date Serviced Item/Description unit Order Qty Quantity Unit Price Total Price 12114/2017 HOLMES JR., J JOSEPH HOLMES JR. Hours S-25 5.25 87.00 4S6.75 12/14/2017 IT-0000320 FILTER, 400-30 HI CAPACITY 1 Each 4 4 6.61 26.45 12/14/2017 RT TRIP REG TIME TRIP CHARGE Each 1 1 150.00 150.00 CD 12/12/2017 SITE NAME: SYSCO SITE ADDRESS- 4500 CARP DR Concord ND 28027 CALLER NAME: Josh Callahan PHONE NUMBER: 704-723-6067 BILL TO: SYSCO CU5T-0001993 was verified as the bill to, PO NUMBER: Josh Callahan HOURS:24 hours PRIORITY: P2 DESCRIPTION: The customer states there are small leaks in the fuel pumps cabinets on pump#1 and #2. DATE:12/14/2017 TECH INITIALS: JH EQUIPMENT SERVICED: Gasboy Atlas dispensers ISSUE ENCOUNTERED: Pumps #'s 1 & 2 leaking CAUSE: Multiple - all filters leaking and several meters and piping bolts Ioase RESOLUTION: Wiped everything down everything as much as possible - replaced all the filters and went around and checked and tightened every loose bolt - tested and monitor for a while problems did not reoccur while on site -also had site personnel come out and checked repairs PERSON NOTIFIED: MOD(Josh) SERIAL,4-KWAT020861 and ]fWAT020862 STATCJS!COMPLETE Fault Area: GAS BOY DISPENSER Fault Reason: FILTER Resolution: REPLACED Subtotal: 533.20 Total Sales Tax: 33-82 A FINANCE CHARGE WILL 8E ADDED TO ALL PAST DUE ACCOUNTS Total: 667.02 FMI 4 Remit To: Jones & Frank PO Box 531829 ATLANTA, GA 30353-1829 919-838-7555 SILL CUST-0001993 TO: SYSCO 4500 CORP DR Concord, NC 28027 3/5/2018 Date Serviced Item/Description SERVICE INVOICE: PSER-0367073 Page: 1 r i. WR Il�1 {J5 I?00I993 ' T YSCD' 4500 CORP DR ---Co"ard, NC 28027 Misty Durham Net 30 Days unit Order Qty Quantity Unit Price Total Price 2/24/2018 SUBCON SUBCONTRACTOR Each 1 1 312-50 312-50 REQUESTEDSERVICES SITE NAME•SYSCO SITE ADDRESS: 4500 CORP DR Concord NC 28027 CALLER NAME: Misty Durham PHONE NUMBER: 704-723-6048 BILL TO: CUST-0001993 PO NUMBER: Misty Durham HOURS: 24/7 PRIORITY: P3 DESCRIPTION: They need to have a line tightness test & leak detection test done at the site SPECIAL INSTRUCTION: They would like a tech on site Man moming in between Sam -gam please contact Misty with ETA 704-723-6048 Precision Test of Line & MLLD A FINANCE CHARGE WILL BE ADDED TO ALL PAST DUE ACCOUNTS Subtotal: 312.50 Total Sales Tax: 21-88 Total: 334.38 ....SUPERIOR P.O.- Box 95 Hendersonville, NC 28793 Tel- Fax-(828)698-6294 www-superiorservices.ua CUSTOMER .gaoled 9. Frank = hadoue sysc.0 00 Corp Dr Concord, NC 2802 RJUV41NA DATE INVOICE NO. 4 .21241201B 131977 TERMS P,0- NO, Net 15 See below LOCATION DEscRiPTm QTY RATE AMOUNT T 7,7 P�t Test of Uns & MLAD 50.00 0,00 . appruclato your W5.iness. Total. lf)WOS�t Of I-1r2% ;.mr moh to .bo paid pn aH masiercwor uiscovar, Am erlcari xpd "Where InNgrify a Haber of Record Service Report DATE: 3/26118 CUST-0001993 Work Order Number #: WO-00005775 SYSC❑ Location: SYSCO 4500 CORP DR 4500 CORP DR Concord, NC,28027 Concord, NC,28027 WORK ORDER DETAILS Caller Name JOSH N/A Product Name Caller Phone Number 704-723-6067 Product Description PO Number JOSH Serial/Lot Number K07207439705001 RKIPROBLEM DESCRIPTION BOOTS NEED TO BE LOOKED AT IN SUMP, ON SECONDARY PUMP MISSING A SHADIER VALVE.. BOOTS UNDER THE MANHOLE, FOAM NEEDS TO REPLACED. -- installation (improper installation)-940 ATC Probe-1343 Replace Tank Farm Component-2205 WORK PERFORMED JRP 3-26-18 Surveyed site and took photos. Discussed with .cosh the state NOV and what can be done to fix it. Sent photos to Shawn Bernas for quote- er 7Nbe Product Name Product Description SeriallLot Number Fault Cause Remedy Work Order Scope Of Work/Problem Description Number Work Order Work Performed Number Customer Signature:. Technician Name: Joshua Pblkey Work Start: M6118 3:17 PM Work End' W26/18 4:09 PM Customer %holu c Usforner Nzinelosh Callahan CUST-0001993 SYSC❑ 4500 CORP DR Concord, NC,28027 Service Report Work Order Number * WO-00005775 Location: SYSCO 4500 CORP DR Concord,NC,28027 DATE: 4/5l18 Caller Name JOSH N/A Product Name 848290-122 OEM Caller Phone Number 704-723-6067 Product Description TLS-350R BIR CONSOLE WITH INTEGRAL PRINTER PO Number JOSH SeriallLot Number K07207439705001 BOOTS NEED TO BE LOOKED AT IN SUMP, ON SECONDARY PUMP MISSING A SHAKER VALVE .. BOOTS UNDER THE MANHOLE, FOAM NEEDS TO REPLACED... Installation {improper installation}-940 ATC Probe-1343 Replace Tank Farm Component-2205 WORK f J R P 3.26.18 surveyed site and took photos. ❑iscussed with Josh the state NOV and what can be done to fix it. Sent photos to Shawn Bernas for quote. JRP, KW, JD 4.5.18. Removed all existing boots from sump. Threaded TCI pipe boots were damaged and threads were not reusable, this was not determinable from the survey because the boots were heavily covered in sealant. Removed threads and ordered boot to directly fit to the wall. Installed conduit boots. Cleaned area around sump of excess dirt and grime. Team will return to install final boots and do under dispenser work. Work Order Scope Of WorklProblem Description Number Work Order Work Performed Number Customer Signature: Technician Name:. Joshua. Pelkey Work Start: 3126118 1-1-7 PM Work End: 4/5/18 2:43 PM Rus Pmer Wn c a Momer N sh Callahan Service Report DATE: 5/16118' GUST-0001993 Work Order Number #: WO-00005.775 SYSCO Location: SYSCO 4500 CORP DR 4500 CORP DR Concord, Id.C,28027 Concord; NC,28027 -,.:5:: �. fir:: •ssr .sue t"..,^.... .K •W"-....�..Y• ris';a,..:.u"re ,"Y r . n• ; .;it%`:`"�� `fizr ; . � .'Y.�.`�:---x �„�1°5�.�;;°<s I.x�d-y.: +:•wl�,��rr �-;.�f _:�s'..i.=: �_:.�fa.�s'..y� �..ua.�s '• �_:.�f:: �s"'r� .0 J:::a::� rh',a:.� J"',a:.� .h�•,^...e .J.". •�<r vim _ ,J.0 v.�`:` "ice`• _'�, :� `•.ii�' ,- .J." �.:a`:` rh;'rY MY;'rY Mn,'rr ' MY;'rY �`nrci ��'r•�:-,^� �.. rci �� � ,^� �'-' .. rci ��''�-;�:-,--x•��r ,; ��'r.'��r;� � r_:.�fzh' "ram: ' S'ircr . re J..�?M _ ,J.0 .�`:.`� c„ice" =^�; �^ .•.�`:`r�,r ::C,rr [, Y ;•- �-.�• & i �'r.� �:-,--x•�,;. r ,iY i'-�.�� ;� :::. x�;a��R� ,�diiw� � �•`c -��-. -. :sd.''w. ,c-F:., .3 3, .v, in', ..z ,.?. .`?S' - s.Q'x� .... F.i. fin'.".,."."... "ix::w•r az�...3.'.'�..."i. r�.:. 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':• 1.� zT.Sya�i t.; .S rfi. �•'- L�zcS..' i�z-�, r.�..i--t' z�k,' .%4 �. �.,� `i. k,' .i �.�'$rr��:, ��:,_ t :- Replace: Tank Farm Component-2205. � �r, 42���..�s q'� f �cy7�'y�`� ` l%� '�`�.,.rj'� �>r'1��j-q' 'ic��,rcr-�� t��.���"••y�` ''c�G�`j#� c��z�6''j�?S��' •'��j �Y' Y 3r`i���k d �� � ��7#��>�; `-�� '�c�c�j#� � k�}' �.. rc� n FL,�;.r"�;'j. � s-,.J,=,+...k ;f =.ls. 3 _�C7�"�.-1.N�_, 3 s �rl:a =,,l.N�_�1 s• � �r�.a� �lr-"F� .,=.-1.N�,� 3 3 ���--l.s "�, i•.��r.,'cl .r � _�C7h�.= rxJ.=��'C1�;r �.�' _��iCF�. a,i .�-:r+r".....5 •s:;- ",.r�.�`.;. �i;.._;•nrry'.,.-L �. ",.r�.x.., ,�-.rzr..,.z- �. ",.ram. ...�:.=..rzr.. .>� �. ,' -... "rzr... JRP. 3.25A 8 surveyed site and took photos. Discussed .with :Josh the state .NOV'and what can be done to fix it. Sent photos to Shawn Bernas for quote. JRP, KW;.JD 4.:5.18..:Removed all existing boots from sump.: Threaded TCI pipe boots were. damaged. and threads were not reusable,: this was not determinable from .the survey because .the boots'Were heavily rove red in sealant: Removed threads'and,ordeired boot. to d irectly. fitto the.wal1. Installed condpit.boots. Cleaned area around sump of excess dirt and grime. Team will return to install final boots: and do under dispenser work. 4.10.18 JRP JD and BH Installed pipe (loots and. showed.Mahager Josh the progress of repairs, STP sump:completed. T-Mobile returnto work .under dispenser. 4117 SB arrived on.. site checked in with Josh; thencleaned dispenser sumps'and STP sump., Hydrostatic tested STP sump found fail but may be due to conduit ; will check. resuIts in the morh1fig.:Alsd all. UDC boots.are defective will need to change quote and install boots on the outside. UDCs have 2 lines., 3 electrical and:2.Iines 2 electrical. 4 testable boots. will. need 2 Testablesln STP. sump as well. 4118,18 SB JRP 6H.JD'pumped water out, made repairs,. once repairs.dry will test again. Discussed quote with. Josh for UDC work' 4120118'JD Cut concrete at. dispenser will return nextto bust up and install boots.on outside of the. sump...4125; and'4126 on site excavation completed buifding side of dispensers.. Installed new entry boots and hydro tested. Filled in excavation with prock.and made ready for concrete. 4127'5B on4te:instaIled . issue'with test. water.found hoot issue: ,. corrected. Retested both 0DCs.again. and. shared up boots. Back filled and will install concrete Monday'. tw3 SB on site cleaned up degree from excavation and hauled it off: Set up compressor and jack hammer for:tomorrow. 5177 518 jack hammered and excavated other.side of dispensers.. 519 SB installed all electrical boots. and started preps dng.Iine boot instaIlatio..n..5/10 installed line. entry and. tested. UDCs for tightness. 5111 SB,BH,JD and KW on site finished installing and testing sumps today :all passed, .Prepped excavation: for concrete.tomorrow. I will hav a superior testing out next Wednesday to test double wall lines...5116. SB;JP,. JD and KW on site checked .'in then pulled l.dispensers and replaced double wall line boots: Superior should be out -on Friday to test': Work -Order Number Produat`Name Product Description Serial/Lot Number Fault Cause Remedy Workrder Scope: Of Work►Problem Description Number Work Order Work Performed Number Customer Signature: Technician Name: Shawn J Bernas Work Start. 3/26118 3,1.7 PM Work End: 5/16/16 4:59 PM Customer 5itinature us Omer ame: osh Callahan Service Report DATE: 7113/18 CUST-0001993 Work Order Number #: WO-00032904 SYSCO Location: SYSCO 4500 CORP DR 4500 CORP DR Concord, NC, 28027 Concord, NC,28027 Caller Name Mlsty Durham Product Name DISP-9840KX DFZ Caller Phone Number 704-723-6048 Product Description REMOTE DISP SGL, FRONT NOZZLE PO Number Misty Durham Serial/Lot Number AT020862 Replace meter follow up from WO-00017236 Leak (nozzle, hose, and so on)-710 Meter, Other - 0590 Replaced-2200 RVOMERF,- ■ 7-12-2018 mt dispenser meter leak. Removed existing leaking meters from dispenser 1 and 2. Replaced with new meters and meter check valves due to humbug. Calibrated dispensers, purged air out of lines. Work Order Scope Of Work/Problem Description Number Work Order Work Performed Number Customer Signature:. ON CilStOmef'SI nature u.s"�vmer Name:.misty durham Technician Name: Mark Taylor Work Start: 7113/18 9:12 AM Work End: 7/13118 3:15 PM rm�k Remit To: Jones & Frank PO Sax 531829 ATLANTA, GA 30353.1829 919-638-755S WILL CUST-0001993 TO: SYSCO 450p CORP DR Concord, NC 28027 7/2/2018 JOSH 3 JUL 12 L..J SERVICE INVOICE: PSER-0393953 Page: 1 SM Work Order No.; WO-00005775 SHIP CUST-0001993 TO- SYSCO 4500 CORP DR Concord, NC 28027 Net 30 Days Data 5ervked Item/Description Unit Order Qty Quantity Unit Price Total Price 5/9/2018 IT-0028003 2-PART 250MIL POLY ADHESIVE Each 2 2 217.35 43430 4/17/2018 IT-D039286 SPLIT FRP THREAD ON RTFT FITTING FOR Each 2 2 202.30 404.59 3/4IN TO 411012019 IT-0040206 SPLIT FRP RETROFIT KIT FOR 1.51N FLEX -PIPE Each 2 2 277.57 5S5.14 W/ 4IN 4/26/2018 IT-0040664 RETROFIT KIT, 8 BOLT REPLACEMENT FOR 2FT Each 1 1 258.75 258.75 FRP PIPE 4/26/2018 IT-0028003 2-PART 250MiL POLY ADHESIVE Each 3 3 217.35 652.05 4/26/2018 IT-0036854 RETROFIT KIT, 8 BOLT FRP FOR 1.5IN PIPE Each 3 3 277.57 832.70 4/26/2019 IT-0028001 SING WAL SPLIT FRP RETRO FITTING Each 6 $ 141.61 1,132.85 4/10/2018 DAVIS, J A JUSTIN DAVIS Hours 4.25 4.25 97.00 369.75 4/5/2018 WALTERS, K KAGE WALTERS Hours 7 7 87.00 609.00 4/5/2018 RT TRIP REG TIME TRIP CHARGE Each 1 1 150.00 150.00 4/17/2018 BERNAS, 5 SHAWN BERNAS Hours 4.25 4.25 97.00 369.75 4/17/2018 RT TRIP REG TIME TRIP CHARGE Each I 1 150.00 150.00 4/18/2018 PELKEY, J JOSHUA PELKEY Hours 3.5 3.5 87.00 304.50 4/18/2018 BERNAS, 5 SHAWN BERNAS Hours 3.5 3.5 87.00 304.50 4/18/2018 DAVIS, J A JUSTIN DAVIS Hours 3.5 3,5 87.00 304.50 3/26/2018 RT TRIP REG TIME TRIP CHARGE Each 1 1 150.00 150.00 3/26/2018 PELKEY, J JOSHUA PELKEY Hours 1 1 87.00 87.00 4/5/2018 DAVIS, J A JUSTIN DAVIS Hours 7 7 87.00 609.00 4/5/2018 SUPPLY ACETONE AND RAGS FOR SUMP CLEANUP Each 1 1 100.00 100.00 4/5/2018 RT TRIP REG TIME TRIP CHARGE Each 1 1 150.00 150.00 4/5/2018 PELKEY, J JOSHUA PELKEY Hours 4.75 4,75 87.00 413.25 4/20/2018 DAVIS, J A JUSTIN DAVIS Hours 4 4 87.00 348.00 4/20/2019 WALTERS, K KAGE WALTERS Hours 4 4 87.00 348.00 4/26/2018 RT TRIP REG TIME TRIP CHARGE Each 1 1 150A0 150.00 4/26/2018 RT TRIP REG TIME TRIP CHARGE Each 1 1 150.00 150.00 4/25/2018 BERNAS, S SHAWN BERNAS Hours 6 6 87.00 522.00 4/25/2018 DAVIS, J A JUSTIN DAVIS Hours 6 6 87.00 522.00 4/26/2018 BERNAS, S SHAWN BERNAS Hours 5 5 87.00 435.00 4/26/2018 WALTERS, K KAGE WALTERS Hours 2 2 87,00 174.00 4/26/2018 DAVIS, J A JUSTIN DAVIS Hours 2 2 87.00 174.00 4/27/2018 RT TRIP REG TIME TRIP CHARGE Each 1 1 150.00 150.00 A FINANCE CHARGE WILL BE ADDED TO ALL PAST DUE ACCOUNTS 5ER'VICE' INVOICE: PSER-0399953- Resn'itTo: Janes:&,Frank. Paget POSOX-531829 Sty Work Order No. W.0-uc 5775 AT.LAPrITA,,"- 30 S3'-�929 919�83&755a� BILL CUST=6091993 S14IP; CUST CW1993 T4: SYSGO TD SYSCO 4%0 CORP. DR 4500. CORP DR Cgn�dd, NC -28027 Cantord,.K' 28027 INVOICE DATE PC) PAYMENT -TERMS CALLER NAME 7j2�201$ JOSH �et30 pays 4127./2018 RT TRIP REG TIME TRIP CHARG E E&h' 1 1. '150.06 '150:00- 4/27/P018 SERNA5:S: SHAWN BERNAS Hours 5n25. 10:2.T 87.4Q 84. '75: 4/27J;.'4I,8 WALTERS, K KAGE'W4TERS Hours 8 8 87:0a `696.00 4127/2418 DAVI5,J A JUSTIN,bAVI5 Flours $ 8 6;06 OECD 4/30/2018 RT-TRIP REG TIM E TRIP CHARGE 'Each' 1 1. 150.00 150.00' 4/30j2018 RTTRIp RFIP:TIMETRIP. CHARGE Each 1 1 150.00. 1501.40 4l/3bj2018 oRVIS;.! 1E'. lUSTIN DfIVIS Hours 6.5 615- 87,00 •565.50 4t36/2018. WALTERS'K KAGE WALTERS Hou rs 6.5 6.5 e700. 565,50: 4/35/2018. SUPPLY -MISC. SUPPLIES Each . 1• 1 225.00 125:00 513/2018; RTTRIP REG LIE i`RIP. CHARGE Each ] 1 150J)0 15010 513120.18- SERNAS, S- SHAA N'kkNAS Hours 5.: S 87.04. 435.40 3/9/2018 RTTRIP REGTIME TRIP CHARGE: Each > 1 150.00 1SO.Q0, 5/912018 BERNAS, S SHAWN B]ERNAS Flau.rs. 175 1.75 87.00 152.25 5/10/2018 REPAIR, C0NCR£TE„REBAR,'b0VVELlNG Each A. 1 350.00 35OAp: 5/10/2RIS RTTRIP 7REG11ME:FRIP-CHARGE' Each 1 1 150.Ofl 150.00; 540/2018, RTTRIP REG TIME TRIP, .CHARG�- Each 1. 1 15.6.00 J.SQ,QO, 5/10/2018 BERNA9; 5' SHAWN HERl�[AS Hours 8 8 8.7:bD 696,04 511Oj2018 WALTERS, K KAGE WALTERS Hours 7.5.: 7:5 87A0 6smb S1.1012018 DAM J A )US-gN DAVIS Hours. 7.51 7.5 87.00 652:50 5/.10/2919 RTTRIP REG TIiv1E TRIP CHARG E, EaCh 1 1 7,50:pti I-50.00. 511W2018. RTTRIP RRG'TIME:TRIP CHARGE 'Egh 1 1-. 15p.Ob 150.OQ• 511A/2018 SEiiN S, S SHAWN 6EkNAS Flours 8. 8. , 87.00 696.4fl 5/10ppt g WALTERS; K KAGE WALTERS Hours 7.5 7.5 8T;G0 .652,50 5110/20I8 gRt115: J A JUSTIN�.R.AVIS: Hours 7.5` 7.5 L87.09 652.50. 5116/W18' RTTRIP REG'iTIMF.TRIP CHARGE Each 1 1. JSO.FiO 3S[].DO 5/16/2018 RT TRIP REGTIM E TRIP CHARGE Each 1. .1 157.00 150.00 5115/2010: 'BERNAS, S; SHAWN SERNAS Haul's 8 8 87:00 695.00 5]1512018 DAV15, J•A 41J5T 1.17AVi5. HaurS•. B $ 57xv 59E.00 5/1613i118- WALTERS,, K KAGE"•WALTERS Hours 8 8, 87.0 W.00 560" NEEb-TO 9E LOOKEDATIN SUMP, ON SECO•NDAKTPLIMP MISSING ASHAUER:VA€ VE... BOOTS UNDER"fiiE:Ju1A¢{F10iE,,FOAM NEEDS TO REPLACED;..•, JRP.1: 6.18 5urveyad �sRe and'took.p"ps. Dis-cussed .w ith.lasti'tbe state kbVand ►vhat Gan be done:ta fik it. Sent p6otgs .p, Shawn Bernas A FINANCE'Ci .RGE WILL, S1 ADDEDlo-ALL PAST DICE ACCDUNT�S e:in hetni4 To:. :lone. & Frank' P.D Box 531 .29 Ail.ANTA,.GA 30353-Z829 91949.9-7555 BILL CUST�OU01993• TD;- SYSC(? 450'CORP DR' Coudrd, NC 28027 SEROM NVOIc�PSER,d393s53 Pace; 3' SM Wark Order Nbz WO-II0005775 SMp, OUST-GOU1993 TO; SYSICO 45W.ODRP DR - Concord, NC-:28U27 INVOICE DATE CUSTQUlER PO PA'YMIENT Tl RNIS CALLER NAME 7/212619 JOSH: filet 3tI`bays• for qutite.- JRP;KW, Jt7'4;5.1&. Removed. eli existing bv�tsiro[ri'slrmp. Threaded TCI pipe boots we:e'da'maged.and lfiiiads Were. not reusable, tKs.was not detem ina.ble•from the.survey.because the boots were heavily cove md.In; sea lanK Removed threads ar=d ordeimd,boof todirectlpfitto.& mia31. Installccllconduit bvpts. •Cleaned ,area around. sump of excess dirt and 9rirne. Team w111 t'eturn to install final boots and do uriderdispeitserwork.. 4.10.18 JRP JD and &N:Installed pipeioaots'and showed mari•ager:Josh ther p'rogreSs of repairs, 5TP sump toinplited. T-Mofalle return wwork:under dispenser. '447 5B a0vdd on site.checked inivlth. Josh, _than deaned•dlspenser- sumps -and. STP•sump: Hydrostatic -tested STP sump.found•fal1: but:rrray 6dua to conduit: wilt &et:k results_ in -the .morning, Also al€ 6K.i pots are Oefec a WIdreed to'change;quote.and install.hoots-oi'i the outside, UD4k leave Zlines, 3`ejectriial and_2.Iines2 electrtcai.4 testable .bvpts: wit€ heed Z Testables in 5TP stuhp,as well. A:] 8.38 58 lItR:BH: ii]. pun'i'ped. water out trade impairs; once• repo€rs:dry iR�f H test again. Dlseussed quote with Jost0or.,0Dl Worse 4/20j18 JD. Cut concrete at dlspenser%Al return nest to bust up anti Install boots on outside of• -the sump. 4/25-and 4/26 an site excavation cgmpfeted #wilding•side of.d1spensers:Installed -new eribyaboots and hydro, t W-. Tilled in e,xcavafloh with, prock and?mado- re* for concre.te- 4/27 $9 oil -site`install ed•issueWitFs'test:woOr found boat issue, Corrected: Ret6te4 bc.hLJDCs;agairrand shdred up boots. •6ackfilled anal ve"II install aon&ete.MvndEV. 5/3 56 ari site cleaned up degree'from.excavatlorl and hauiedtt.off: Set• up•compresser and:jackhamner for tomorroia. 5f7'- 5/8jackfidmrtlered an•d extavated other side;of dispet:sers, W. 1ngt6ifed. ail;electrii:al 6apts;and •t#arted prgparing.line boot•instaliation. 5110:instalied NO0ent y:and'#e *s Aj%0 for 00hoess:- 5/1.1.5B, Bli, JD a Md- KW. 6n-site finished installing and.testin9 sumps,today, all passed, Pnipped ext?0vdtion:foreoncrete tamarrow..I will have superior te0' atlt.next Wednesdayto.test:tfauple wail lines. 5/16.5$, JP J0 and.;KW on site checkedin than pulletf. dlspensers,and replaced double•vial E line boots. 5u.psriorshould. be: ot#t on Friday'ta test:. AD(3iT1ONAL 1NO]iK 5/31trJ.6/1 Testing and rarriplianCk. Superior Linable to retuni.to meet N6V daadllne,so!&F•fihiihi3d rampliarrcy poling dispensers'fill€ng with'vrdter rid ecking Hydrostatic 5 cant4inm0nfl houriesis-plus r6o�ing and reclaiming test water. -used origInaI.-tesi dates. againsi.retaairtfrnes. 10.hours occurred y1700 2 meR. Test tioulile waif line boots, had'ta,puII dispenses, adjust Hoots to propertest poi nIs`dn piping, reseal test.Imo[s, instal€'gaucyes,, test rern6Ve g qugL5, and putdispenser; l,ackorl €.land In working condition, 4 lines 1 noelr test, plus.. physical 18bWof4.men@10h0urs= $3400. Actual E-is.25K, Add $51,04 ta<Ougte-forihe-actual e> perm of fl r3al :A&CUTIaNAL INraRMATION fauItArea;• FaultReasdn: PIPINGITANK/5IPHON Resoldtiort: REPLACE TANK•FARRCOMPO LENT A F1NANCk. CHAKGE vI1kL BE-ARt7ED.T9 ALL MsT RGE Accou Ts Sulatota l: -. 23;63Z6s Total Sales Taxis. 1,458.24 Taw:.. 24:994.27 Violation 5: 15A NCAC 2N .0603 IILS3 UST-17B UST Suspected Release 7 Day Notice E�y This form must be used to report to DEQ, within 7 days of discovery, the investigation results for a Suspected Release from any of the following: a) Failed or inoonclusive leak detection or tightness test results. This includes positive test results, such as "Increase", which indicates 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; the unexplained presence of water in the tank; the presence of fuel in containment sumps or interstitial spaces; or the degradation of any equipment or element of an underground storage tank system to the point where that equipment or element can not reasonably be expected to perform its intended function. c) Internal inspection results such as, perforations, corrosion holes, weld failures, or other similar defects that indicate a release could have occurred. If you have more than four UST systems to report suspected release investigations, then attach additional sheets of the UST-17B form. Y Please submit this form along with the supporting documentation to: NCDEO/DWM, UST Section 1646 Mail Service Center Raleigh, North Carolina 27699-1646 OR Fax to (919) 715-1117 OR UST.Permits(ancdenr.gov I. UST OWNER II. UST FACILITY Name: Name: Facility 0: Sysco Charlotte LLC Sysoo Charlotte LLC 00-0-0000035443 Address: Address: 4500 Corporate Drive NW 4500 Corporate Drive NW City: State: Zip: City: County: Concord INC 28027 Concord Cabarrus Person Reporting: Title of Person Reporting: Telephone Number: Josh Callahan Fleet Manager (704) 723-6067 III. INVESTIGATION RESULTS Tank Number/ Size: 1 / 20,000 Gal ! 1 1 Product Stored: Diesel Reason for Suspected ❑ Data entry error' ❑ Data entry error ❑ Data entry error' ❑ Data entry error' Release Investigation ❑ Dispensing fuel while ❑ Dispensing fuel while ❑ Dispensing fuel while ❑ Dispensing fuel while (Check all that apply): test is being conducted z test is being conducted s test is being conducted 2 test is being conducted ® Faulty equipment 3 ❑ Faulty equipment' ❑ Faulty equipment' I[ Faulty equipment' You must attach the ❑ Incorrect stick or meter ❑ Incorrect stick or meter ❑ Incorrect stick a meter ❑ Incorrect stick or meter supporting documentation reading' reading' reading' reading' specified in the footnote for the reason(s) selected. El Incorrect tank chart a ❑ Incorrect tank than: s ❑ Incorrect tank chart ❑ Incorrect tank chart Internal Inspection 5 ❑ internal Inspection 5 ❑ Internal Inspection 5 ❑ Internal Inspection 5 ❑ Meter not calibrated g ❑ Meter not calibrated c ❑ Meter not calibrated e ❑ Meter not calibrated e ❑ Other (Attach ❑ Other (Attach ❑ Other (Attach ❑ Other (Attach explanation)' explanation)' explanation)' explanation)' ® TankfDispenser ❑ Tank/Dispenser ❑ Tank/Dispenser ❑ TanklDispenser containment sump containment sump containment sump containment sump contains liquid' contains liquid' contains liquid 7 contains liquid' ❑ Tilted tank a ❑ Tilted tanks ❑ Tilted tank a ❑ Tilted tank s ❑ Unknown' ❑ Unknown' ❑ Unknown' ❑ Unknown' ' Conduct a tank and/or line tightness test and attach the results, along with all of the supporting data sheets for the test method, to this form for submittal. The summary page listing the results by itself is not acceptable. If the tightness test results are fail, then you must repair or replace your UST system and conduct a site check in accordance with 15A NCAC 2N .0603. z Provide sales receipts or other comparable documentation that shows fuel was being dispensed from the UST during the test. 3 Provide invoices (with a description of the work completed) or other documentation that shows the equipment has been repaired. { Correct your leak detection results using the correct tank chart and submit copies with this fort. 5 Repair the UST in accordance with the manufacturer's instructions or a national standard (e.g., PE API 1631) and conduct a site check in accordance with 15A NCAC 2N .0603. If the UST is not repaired, then it must be permanently closed in accordance with the latest version of the UST Sections Guidelines for Tank Closure- " Correct your leak detection results using the amount your meter was adjusted following calibration and submit copies of the meter calibration and leak detection results with this form. 7 Conduct a tightness test (e.g., hydrostatic test) of the sump and submit the test result along with this form. If the test results are fail, then you must repair or replace the containment sump and conduct a site check in accordance with 15A NCAC 2N 0603. s Submit documentation from your UST equipment contractor explaining how they determined the UST was tilted. Correct your leak detection results using a tank chart adjusted for the tilt and submit with this form. Note: Tank, piping, spill bucket and containment sump replacements must be done in accordance with 15A NCAC 2N .0900 UST-17B Revised 1012015 http:ifwww.wastenotnc.org/web/wrn/ Rarnit To: Jones & Frank PO Box 531829 ATLANTA, GA 30353.1829 919-838-7555 BILL CUST-0001943 TO: SYSCO 4500 CORP DR Concord, NC 28027 SERVICE INVOICE: PSER-0349908 SHIP: CUST-0001993 TO.- SYSCO 4500 CORP DR Concord, INC 25027 Page: 1 DATE CUSTOMERINVOICE •s PAYMENT TERMS CALLER NAME 12/21/2017 Josh Callahan Net 30 Days Date Serviced Item/Description Unit Order City Quantity Unit Price Total Price 12!'4,2017 HOLMES )R., J JOSEPH HOLMES JR. Hours S.25 5.25 87.00 456.75 12/14/2017 IT-0000320 FILTER, 400-30 HI CAPACiTY 1 Each 4 4 6,61 26A5 1211412017 RT TRIP REG TIME TRIP CHARGE Each 1 1 150.00 150.00 SERVICES REQUESTFE) CD 12/12/2017 SITE NAME; SYSCO SITE ADDRESS: 4500 CORP OR Concord NO 28027 CALLER NAME Josh Callahan PHONE NUmBER: 704.723-6067 BILL TO: SYSCO CUST-00D1993 was verified as the bill to. PO NUMBER: Josh Callahan HOURS: 24 hours PRIORITY: P2 DESCRIPTION: The customer states there are smal? leaks in the fuel pumps cabinets an pump#1 and Q. 'SERVICES PER�ORMED DATE:12/14/2017 TECH INITIALS-JH FOU;PMENT SERVICED: Gasboy Atlas dispensers ISSUE ENCOUNTERED: Pumps #'s 1 & 2lea king CAUSE' Multiple - ail filters Ieakin 9 and save rai meterS and piping bolts loose AESOLUT10N: Wiped everything down everything as much as possible - replaced all the filters and went around and chetked and Iightened every loose bolt - tested and rnon1tor for a while problems did not reoccur while on site also had site personnel come out and checked repairs PERSON NOTIFIED: MOD(Josh) SER1ALd*,1CWAT02nM51 anti VWAT020862 STATUS:COMPI E7E ADDITIONAL INFORNIANON Fault Area: GASBOY DISPENSER Fault Reason FILTER Resolution: REPLACED Subtotal: 633.20 Total Sales Tdx: 33.82 A FINANCE CHARGE WILL BE ADDED TO ALL PAST DUE ACCOUNTS Total; 667.02 rim Remit TO: Jones & Frank PO Box 531829 ATLANTA, GA 30353-1829 919-838-7555 BILL CUST-0001993 TO: 5Y5CO 4500 CORP DR Concord, NC 28027 SERVICE INVOICE:PSER•0386066 Page: 1 SM Work Order No.: WO-00017236 SHIP: COST-0001993 - _ TO' 5YSCO 4500 CORP DR Concord, NC 28027 5/30/2018 Misty Durham Net 30 Days Date Serviced Item/Description unit Order Qty Quantity Unit Price Total Price 5/25/2018 IT-0008088 A55Y CFT METER Each 1 1 307.92 307.92 5/4/2018 RTTRIP REG TIME TRIP CHARGE Each 1 1 150.00 150.00 5/4/2018 TAYLOR, M MARK TAYLOR Hours 1 1 87.00 87.00 5/25/2018 RTTRIP REG T1ME TRIP CHARGE Each 1 1 150.00 150.00 239.25 5/25/2018 VELASQUEZ, A AMILCAR VELASQUEZ Hours 2.75 2.75 87.00 REQUESTEDSERVICES They need to have two GiIbarco meters replaced they have a small leak PERFORMEDSERVICES 5/4/2018: Mt lea icing meter. Checked meter for leaks. Meter is leaking, need to order 2 meters (T20150-G5). Will return when parts arrive. 5/25/2018 AV - Replaced meter on dispenser 1 and calibrated. Work order complete. ADDITIONAL Fault Area: Fault Reason: METER, OTHER Resoiutlan: PART REQUIRED + ► k. TO R ky I NO, S-ALI'S 'I'.11 Subtotal: 934.17 Total Sales Tax: 44.39 A FINANCE CHARGE WILL BE ADDED TO ALL PAST DUE ACCOUNTS Total: 979.56 Violation 6: 15A. NCAC 2N .0901 SECD3 Triennial UST Containment Sump J UST-fiFI238 UDC Integrity Testing _...� • If any periodic test fails, a suspected release report must be submitted on a UST-17A form, USTSuspected Release 24 Flour Notice. The suspected release must he investigated, in accordance With 15A NCAC 2N .0603, and defective equipment repaired or replaced 1n accordance with 15A NCAC 2N Results of the investigation must be submitted on a UST-17B form, UST Suspected Release 7 Day Notice. .04041.0900. • Containment sumps installed on or after 1111I2007 that are not monitored continuously for releases using vacuum, pressure, or hydrostatic interstitial monitoring methods and all other containment sumps installed prior to 11MQD07 that are used for interstitial monitonng shall be tightness tested at installation and every three (3) years thereafter in accordance rn+ith the manufacturer's written guidelines, PEURp100'Recommandad Practices for Installation of Underground Liquid Storage Systems" andlor PEIIRP1200'Recommendad Practices for the Testing and Verification of Spill, Overfill, Leak Detection and Secondary Containment Equipment at UST Faculties.° • If a UDC 1 containment sump fails a periodic tightness test, the sump must be Teplaced or repaired by the manuTacturer, or the mane#acturees authorized representative in accordance with the manufacturer's specifications. UST FACILITY Owner 1 operator Name Facility Name Facility ID Sysco gym 00-a-0000035443 Facility Street Address Facility City County 4600 Corporate Drive Concord Cabarrus CONTRACTOR/PERSON CONDUCTING INSPECTIONS Company Name Phone Email address Jones -Frank [7041 393 8542 St�ernas�¢jones-crank com 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 fisted in 15A NC AC 2N .406 andlor 15A NCAC 2N .0900, Shawn Bernas Signature of son conducting inspection May 10 2018 Print Name of person conducting inspection Inspection Date Identify UDGlsump (By ® Dispenser ® Dispenser ❑ Dispenser ❑ Dispenser ❑ Dispenser ❑ Dispenser Dispenser No. or Tank 1Numhef; ❑ Tank # ❑ Tank; ❑ Tank# ❑ Tank # ❑ Tank # ❑ Tank# Tank Size, Stored Product; e. g. 01 1Ok Regular 5TP. Disp Ia. � Dispenser 1 UDC # Dispenser 2 UDC # # # # etc.) iTransition sumps should be listed above as "TS-XX" (with XX= sump IDS) Sump Manufacturer APT APT ❑ FRP ❑ FRP ❑ FRP ❑ FRP ❑ FRP ❑ FRP Sump Material ® Plastic ® Plastic ❑ Plastic ❑ Plastic ❑ Plastic ❑ Plastic Single Wall ® Single Wall El single Wail ❑ Single Wall ElSingle Wall ❑ Single Wail Sump Type ❑ Double Wall ❑ Double Wall ❑ Double Wall ❑ Double Wall ❑ Daublc Wali ❑ Double Wall ® Hydrostatic ® Hydrostatic ❑ Hydrostatic ❑ Hydrostatic ❑ Hydrostatic ❑ Hydrostatic Test Type Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum Indicate units for all measurements Liquid and debris removed from ® Yes ❑ No Z Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No sump? Visual inspection (No cracks, loose parts or separation of the Pass ❑ Fail X Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail containment sump] Sump Depth 36 inches 36 inches Height from sump bottom to top of highest penetration or sump 16 inches 8 inches sidewall seam Wait time between applying 15 mins 15 mins vacUurnm ater and start of test Begin j End Test Time 2:30 PM 3:30 PM 3:45 .4:45 = (minimum test time: 1 hour) Begin I End values 18 inch 18 inch 10 inch 10 inch = Pass/Fail criteria: Must pass v4suat inspection. Hydrostatic: Water level drop of less theft 118 inch; Vacuum: No change in vacuum Test Results ® Pass ❑ Feil n Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fall ❑ Pass ❑IF ❑ Paaa ❑ Fail Comments and explanation of failing results and other problems noted during inspection. Site failed Hydrostatic testing, replaced Entry boots and re tested with passing specs. Date next Containment Sump/UDC integrity test due (required every 3 years) NORTH CAROLINA DEPARTMENT OF ENMRCNMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT. UST SECTION 9MO17 IM MAIL SERVICE CENTER, RALEIGH, NG 27699-1645 PHONE (919) 707-8171 FAX (919) 715-1117 h {pllyn�u_vsest l2G pLt;L Triennial UST Containment Sump ! UST-fiF,f23B UDC Integrity Testing • If any periodic test fails, a suspected release report must be submitted on a USTA7A form, UST suspected Release 24 Hour Notice. The suspected release must be investigated, in accordance with 1SA NCAC 2N .0603, and defective equipment repaired a replaced in accordance with 15A NCAC 2N 134G41.0 900. Results of the investigation must be submitted on a UST-178 form, UST Suspected Release 7 Day Notice, . • Containment sumps installed an or after 1111r2007 that are not monitored continuously for releases using vacuum, pressure, or hydrostatic interstitial manitonng methods and all other containment sumps installed prior to 11A=07 that are used for interstitial monitoring shall be tightness tested at installation and every three (31 years thereafter In accordance with the man utacture r's written guidelines, PEI1RP100 -Recommended Practices for installation of Underground Liquid Storage Systems andlor PE11RP1200 "Recommended Practices for the Tasting and Verification of Spill, Overllll, Leak Detection and Secondary Containment Equipment at UST Facilities.' • if a UDC I contalnment sump fails a periodictightness test, the sump must be replaced or repaired by the manufacturer, or the manufacturer's authorized representatve In accordancewith the manufacturer's specifications. LIST FACILITY Owner 1 operator Name Facility Name Facility 1D Sysoa Sys 00-D-000035443 Facility Street Address Facility City County 45DO Corporate Drive Concord Cabwrus CONTRACTOR/PERSON CONDUCTING INSPECTIONS Company Name Phone Email address Jones --Frank 704 393-8S42 Sbarnas@jones-t►ank.com I certify, under penalty of IaW, 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 andlor 1SA NCAC 2N .0900. Shawn Bernal 5110f2018 Print Name of person conducting inspection Sign�ra��esp�Wion Inspection Date identify UDClsump (By ❑ Dispenser ❑ Dispenser ❑ Dispenser ❑ Dispenser ❑Dispenser ❑ dispenser Dispenser No. or Tank Number. ® Tank # # ❑ Tank # ❑ Tank # ❑ Tank # ❑ Tank # ❑ Tank # Tank Sire, Stored Product; e.g. W 10k Regular STP. Disp 1J2. #. Diesel 20K # # # # # etc.) Transition sumps should be listed above as "TS-XX" lrNth XX= sump ID#j Sump Manufacturer Xerxex ® FRP ❑ FRP ❑ FRP ❑ FRP ❑ FRP ❑ FRP Sump Material [] Plastic ❑ Plastic Cl Plastic ❑ Plastic ❑ Plastic ❑ Plastic ® Single Wall ❑ Single Wail ❑ Single Wall ❑ Single Wall ❑ Single Wag ❑ Single Wag Sump Type ❑ Double Wall ❑ Double Wall ❑ Double Wall ❑ double Wall ❑ Qoubte Wall ❑ double Wag Hydrostatic ❑ Hydrostatic ❑ Hydrostatic 0 Hydrostatic ❑ Hydrostatic ❑ Hydrostatic Test Type ❑ Vacuum ❑ Vacuum ❑ Vacuum 1E) Vacuum ❑ Vacuum ❑ Vacuum Indicate units for ail measurements Liquid and debris removed from ® Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No sump? Visual inspection (No cracks, lapse parts or separation Of the E5 Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail j] Pass ❑ Fail containment aurn p} Sump Depth 46 Height from sump bottom to top of highest penetration or sump 19.5 Inch sidewail seam Wait time between applying 15 mins vacuumlwater and start of test Begin I End Test Time 1 PM 2 PM (minimum testtime: 1 hour) Begin i End values 21.5 Inch 21.5 Inch PasslFail criteria: Must pass visual inspection. Hydrostatic: Water level drop of less than 118 inch; Vacuum: No change in vacuum Test Results IS Pass ❑ Fall I ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fag ❑ Pass ❑ Fall ❑ Pass ❑ Fall Comments and explanation of falling results and other problems noted during inspection: Site Failed hydrostatic, we replaced all boots in STP sump and all tested ok, Date next Containment Sump/UDC Integrity test due (required every 3 year's) 5109/2021 NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, LIST SECTION 912017 1646 ]NAIL SERVICE CENTER, RALEIGH, NC 27699-1546 PHONE (919) 707-8171 FAX (919) 715-1117 http-/tV yW- %0Stenetnc." UST-6H123C Triennial UST Piping Integrity Testing (for components installed on or after 111112007 or when returning NZ any UST system to service from temporary closure) This form must be used to document pipe integrity testing (for piping not monitored continuously for releases using vacuum, pressure, or hydrostatic methods) for UST systems installed on or after November 1, 2007 (this includes existing UST systems that have installed or replaced the piping on or after November 1, 2007) or for any existing UST system conducting interstitial monitoring of the piping regardless of Installation date prior to returning to service from temporary closure, if there are more than five (5) piping systems at this facility, make additional copies of this page. The primary containment and interstitial space of the piping shall be tested in accordance with the manufacturers written guidelines and PEI1RP100 "Recommended Practice for Installation of Underground Liquid Storage Systems_" e The fast periodic tightness test record must be maintained by the tank ownerloperators and must be readily available for inspection. o If any periodic lest fails, a suspected release report must be submitted on a UST- 17A form, UST Suspected Release 24 Hour Notice, and investigated in accordance with 15A NCAC 2N .0603, and any defective equipment repaired in accordance with 15A NCAC 2N .0404/.0900 Results of the investigation must be submitted on a UST -178 form. UST Suspected Release 7 Day Notice. if the piping fails a tightness test, it must be replaced or repaired by the manufacturer or the manufacturer's authorized representative in accordance with the manufacturers specifications. Following any repair, the piping most be re -tested for tightness. UST FACILITY QwrierlDperator Name Sysco Charlotte LLC FacilityName Sysco Qo-o-00 035443 Facility Street Address 4500 Corporate Dri Facility Crty Gaurve Concord Cabarrus TESTING CONTRACTOR INFORMATION Company Name (ones -Frank U—,,.,.. n.., ___ Phone 7043938542 E-mail Address Sbernas@jones-frank.com 101 Northpark Blvd ` ty State Zip Charlotte NC 28216 1 certify, under penalty of law, that the testing data provided on this form documents She UST system equipment was tested rn accordance With the manufacturer s guidelines and the applicable national industry standards listed in 15A NCAC 2N 0900 Shawn Bernas 1_ Print Name of person conducting test ignature of person conducting test fdentify piping system (By Tank Number, Stored Tank # STP line 1 Tank 0 STP line 2 TankSatalite 1 Tank # 5atalite 2 Tank # Tank Size 20K 2OK roduct Diesel On Road Diesel On road Piping Type(, DW E DW Flex DW flex Flex, Other ❑ Gravity ❑ Gravity Piping Configuration ❑ Manifold ❑ Manifold 0 Pressurized 0 Pressurized Piping Manufacturer APT XP gen 2 APT XP gen 2 Pipe Model (Part No,) Indicate Test Phase: ■ Triennial Testing ❑ Post -Install Test Date 6/1/2018 � 6/1/2018 A. Primary Pipe Test (Note: Must be a third -party certified Line Tightness Test 20 K Diesel On Road DW Flex 20K Qiesei On Road DW Flex ❑ Gravity ❑ Manifold ❑ Gravity ❑Manifold ❑ Gravity ❑Manifold Pressurized © Pressurized ❑ Pressurized 177 Suction Suction Suction APT XP gen;2 APT XP gen 2 Return to Service from Temporary Closure 61112018 6I112018 ness test] (Attach test data sheets to farm] Results Attached ❑Yes 0 No ❑ Yes❑ No ❑ Yes❑ No ❑Yes Q Nv ❑Yes ❑ No B. Secondary Interstice Test (indicate units for all measurements) Begin i End test time 1200 11300 1315 , 1415 1430 .1530 1545 j 1645 Begin I End pressure 10 Psi 10 Psi 10 Psi 10 Psi i 0 Psi ]0 PsI ] OPsi 10 Psi Secondary Test Result 0 Pass ❑ Fail f Pass ❑ Fail Pass ❑ Fail e❑ Pass ❑ Fail ❑ Pass ❑ Fail Comments and explanation of falling results and Other problems noted during inspection Double wall testing boots were deemed bad by Superior Testing Co. Testable boots were replaced and adjusted and tested ok. NORTH CAROr_INA DEPARTMENT OF ENVIRONMENTAL QUALITY. DIVISION OF WASTE MANAGEMENT, UST SECTION 1646 MAIL SERVICE CENTER, RALEIGH. NC 27690-1646 PHONE (919) 707.8171 FAX (919) 715-1117 http llwwwwastenotnc or9Meb/wrn 10115 UST-6F/23B Triennial LIST Containment Sump / UDC integrity NC Testing r-; 1 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 NC AC 2N .0603, and detective equipment repaired or replaced in accordance with 15A NCAC 2N .04041.D900. Results of the investigation must be submitted on a LIST-179 form, V S T Suspected Release 7 pay Noboe o Containment sumps installed on or after 11/112007 that are not monitored continuousty for releases using vacuum, pressure, or hydrostatic �nterst bal monitoring methods and all other containment sumps installed prior to t 11112G07 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, PEIIRP10o "Recommended practices for InstaIlatinn of Underground Liquid Storage Systems" and/or FEI1RP1200'Recornmended Practices for the Testing and Verification of Spill, ❑verfi#I. Leak Detection and Secondary Containment Equipment at UST Facilities." i 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. Sysco Charlotte LLC sy' Facility Street Address Facility C 4500 Corporate Dr. Concord WV111por1Y nau'e Phone Jones 3 Frank_ 704393-88i8 I certrfy, under penalty of law, that the testing data provided on this form documents the manufacturer's guidelines and the applicable national industry standards listed in 15A N stage Wafters Print Name of person oonduoting teat Sionaw a o Identify UDC/sump (By ®Dispenser ®Dispenser ❑Dis enser Dispenser No. or Tank Number, P Tank Srza, Shored Product e.g. ❑Tank ❑Tank ❑Tank #4 1Ok Regular STp, prop 1/2. #: FP1 #: FP2 #: etc_) Satalite UDC Satalite UDC Transition sumps should be nstad above as "TS-Xx" (with XX- sump 01111) Sump Manufacturer APT APT Sump Material ❑ FRP ❑ FRP ❑ FRP ® Plastic ®Plastic ❑Plastic Sump Type ® Single Wall ® Single Wan ❑ Single Wall ❑ Double Wall ❑ Double Wak ❑ Double Wall Test Type ®Hydrostatic 0 Hydrostatic ❑ hydrostatic ❑ Vacuum ❑ Vacuum ❑ Vacuum cabanus charionegroup(gjones-Na nk.com system equipment was tested to accordance with the 2N .0408 and/or 15A NCAC 2N .0900. 5-31-18 o acting test Test Date ❑Dispenser ❑L 8panser ❑piSpenser ❑Tank ©Tank ❑Tank ❑ FRP ❑ Plastic ❑ Single Wall ❑ Double Wan ❑ Hydrostatic Cl Vacuum ❑ FRP ❑ Plastic ❑ Single Wall ❑ Double Wan ❑ Hydrostatic ❑ Vacuum ❑ FRP J + Cl Plastic ❑ Single Wall ❑ Double Wall ❑ Hydrostatic ❑ Vacuum Liquid and debris removed from ®Yes ❑ No ❑ ❑ No sump? ® Yes ❑ No Yes ❑ Yes ❑ No ❑ Yes ❑No ❑Yes El No loose parts or separation of the ®Pass [I Fail containment sumo/ + ® Peas ❑ Fail ❑ Pass ❑ Fail I ElPass El FBI ElPass [IFail I IDPass ❑ Fail I Sump Depth 131" 13V Height from sump bottom to top of highest penetration or sump 7" 8" sidewali seam Wart time between applying 1 vacuumlwatei and start of test hour 1 hour Begin i End Test Time 13:Q0 j 14:at7 15:00 j 15:00 (minimum test time: 1 hour) 1 I I i Begin i End values 9' j W I to, i 10, PasslFaII criteria: Must pass visual inspection. Hydrostatic: Water level drop of less than 118 inch; Vacuum: No change in vacuum Test Result ® Pass ❑ Fail ® Pass ❑ Fail ❑Pass ❑Fait ❑Pass ❑Fail ❑ Pass ❑ Fail ❑ Pass ❑Fail Comments— {include MfOrmation an repairs made prior to testing, and recommended follow-up for failed tests) Date next Containment SumplUDC integrity test due (required every 3 5-31-2021 NORTH CAROUNA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT. LIST SECTION 1646 MAIL SERVICE CEI+iTER, RALEIGH, Nl; 27699-f646 PRONE (9i9) 707-al71 FAX (918) 715-1117 9Q017 ttiorRplc�ndegui�a,Trikaems;°Rcon'taUST-E�3] . AIgK INSTALL:A"ilt]NiFRiEHilAi::7�S%IC�Gy A separat�f6nr shodki he used:foc each facfllly, If tigers ark mare than tKe tsj tun4eu at #ris faclNiy, raatie adanlanal copies al:rhls }7age. Vw p irnaryand iiuera"tilial.sliace.oft f tank;s}rall ae tasted'fn ac mdarke islith•11i�:marruf� viers miueie pdrdnlirca� grid PEURPIgvHspammended:Prselice for fnsiallslfan of9Jnd%grouod i:igt,fd Slorage tg terAs.' The lasl peHod cd'ightnsss.tast record most ha. mail hdhed•.bi ttre Wa owner or open tbmod must li�feadlly AirailebletGr tss§pectlar! . o . Tanks. dial -are pet rnori#tnred eont nuously-faf releases usfr�,vacuum; pressur�,.arhydrastaticmetliads inilst'fee-�grlhrless te6ted at.lristallat�re,'hethesst Band 72rn mths frota irlsfallatioil, tsnd.eVery rYlrea years foUapvTng instatlatlon. a The Interstitial. space.of Jh'�q turik.shO be tested itsllig g a id'party ceru iat! interstice tiphtnsss fslcapabla.cf detecting a o_i gph leak tram the inner or ornerrvaat# 4ritip infersSiCefar ills lank•rnt#fal.lhat:7s lnstsl�d.. • p tf rise tanklail's a tlghtness•IOE4it. t lie replaced oi repalredbj the rn@nuf ti rer prthe n a ul&lumes aWhcH6d-mp*66%W ve.€rl•aeearddnce Q5 O the rrwu manuracturer's speclflcatipm. Following any ropalr, fife tank must be re4ested foc fiohtnessAlso-a'suspected j614r3 r6part must $s..5ilbMkte' on a UStLVA form,-USrSLwOded Relaasa,24 f tottrNafiog. Tha suspected relcow must•ba•inve'alyated, irl arcordan.ce Wih .I EA WO2N`.17608, and zany defectivs equ iced in:acaxrdence With I$A.NCAC2N.og041.090i1: Reza fts'af the.'Irpres3 stlan must beisu6nNtied on a-u 3T-:17B %rm.115T 8uspeeied' prneht rfipdtfedlrap Release 7day NoOpe, Wner Fab_ Name tic: 1p#:-{iif100(?i}35443 Opertgtar Mania ao... rase Fac:'cw ounty. 454g COi FOfiATE f]RjVE, NW 'CONCORD CABARRUS Co. Namo. Su sl-lar'seivjtiss Phaittl .... l ,828�698�t3288 daveti�auperigrserirraes:u�' dress. RQ stax-862 city Kendersonvilte-. rate NCh lis 28793 .Kell iGellior - S rspturt3 a person ca urn rag test nG amepf.peraq. can uct rag. Wen* Tank.(Tank,NumGer, etc.) Tank Unit # Tank i Tank#• Tank.Sixe 20000 Nasal piurluct UST Type FRP UST` w,MR Wed J,ache&d,SfeelfCl.RA,.Ofher. IndicatV units for atoll-measur6merils: inches L Pre4nstallatlim testl lyacuurnipressure Gauge ne. Test Date lbterstitial.spa o-Liquld'FRlWd:arY;i um.. Tostmothar#,, Var_uum : f.iqu�d t ledl4 er: Begirt End bm- Time'giquid) Sdki End Levet(fiquld)------------ I ! ! I t Begin Ertl Test l arts. Begin End d. + i. r , I TalikReautt Pass • ail. Pala- Fall i>ass Fag Pass Fart Pass Fall Liqutdvisible on ittsldelouLsid QYsa ad. Yes•NO -Yes No Yes ;hip Yes No df ttrnk(lf e6pOlWabjq) tl: isdat�iriatntleticrtPrlcrinl sf tes�liag Tfghtrress�Tesi Made] (if apigicable), lest bate• Be in . End a3i?r37�0 B IM9218 thter: #hilal spac4.4.fgWd•F016&Dlher: Test inetho'd.. E]Ve ppm XLlquki.fi$editstltar:; ...Xerxes Begin UndT'est7iMR, Ofquldj 1!.33 233 F ; ;. �. In E= d.Leyef.uid �s i . � � 7�.75 ; 12:T5 ; Begin. End Teat Tars Bcqin End, Press ure111acqum i. r Test'>Zesellt Pass all Pass: Fail Pass rail- P.6ss Fail :1PA s Fall lJoluidVisible on ihatido of tank Yes Yes, No Yes -No Yes No: Yes No: NORTH CAROLINA DEPAi3TM�T C3F;ENVIP3(}N)Ar2r4 QUALITY; DJVlSiOKf rIUASWIMMAGEMENT, li5T`5EC,TION [4115 ;fYt6 llilPllL$i FtCIICE Ei+[71=F2, FfA1.EEGH, NC 2]699.18dB. PF7tJ1+lE {$19y.7f7T-$�7,1' F.AX 619) 7950117 trttg IhYoVw;Waslerrptriv;w�j( �fYrrri; Recoin men&d,PrKtlCe5 40f IM TeAn 94n d Vietfflcatjwof Spll I Ovdi I k. Leak -Mection and Secaqdafy-tunjain OiOt EOlpme rit at UST Wl 11fies L; I XERXES Pil making lasting difference TRUCHEK' DATA LIOG, F M a %A- the site 14r.9 . tion, . tank i4dernallon.and jest boxes W19ft #eq-.,b4x -Wprding tp-tbe -d'ameter Otlhe. p.rtk bel hg to-ittd , Follow Tht'lest p rqcedu rm on the.plh er side,of III is. f a rm., Xsepartle test'fqrM Is nee6p ' d- for every tank. Fb r ad chtlonal. capies of -the fogn, cont . acr thaA . Zustomer Servke Repfesen*ive at ihe)(erxes martubkturing hack Cover fpt 'Warm R F: Q C- AT 0 N AND TANK fNF(-)RlNll!`J�C)N Ske Location: syew Fo-od. ser*m of ch aiioaq. mink lnfo.q*Ww-. Addfe,Z- 4606 CorOomte Drive..NW Nominal !Ga"Hons: Phone.,: 7047234W7 Ap Length.- 394 progim-ate Standpipe -CaMahan Diesel Contact Name% Pfqductlype- 3-2 . 42018 KPHY Keiser- 5uPilQr,0Grvke3r lbst.DM6.: Piaimbh Performlhg Test Mnwmur�k mc: 95% - 5% TEST la. Stamlevel Omhesin:standpipe? U But.. kwl bftwr 4 hows (%vbtra -qtbkom lo) A. tlllxaWh fador X. .10 5. Volume dipw 6. lekthom 4 71 6al6SVAMX loss Of 0.05 gat khskrmK cwless, tw--Pasw d) WC.m3ximum Amable dispning volume deriog test: fi4aM-dipmeter.twtk:— 500 9iidk=&.m&xk-nurn 4-ImAldiameter taM � 30t1 aalbm maiHmn 95% - 5% TEST 2W.. End kwi after 6 hGUTS I Dfti0w-(subbaa2 6 framl a) 4, Calbafi6n facw' k .30 51 Vbbme ChaNe 6.. C lesihm. + 7; Gailans-perbmw Ion (it 0A..qpk]DnskwW Orkl% tank pome&) Raw MeAknum a I lowable.. cRspertOng. vp$me, dWW9 mt; 99% -1% TEO 1 a. ,Start kyO 900,ies in #zrWp4m) 2b, End,"fafter-10him r - s 3. Dftrerfa�(2b fiam 1 b) At A Calbatkm fadw 'x .20 5. Wume change ,6.. Tek, hours + 7. GAmimphoyr- loss op-05 galm wflaw or L-51, WA: pafisw Note'No pindlUddispensing -Aywed 99% - I.'%-- TtST- ib, Start level W*s in maridpipe) Zb. Fnd Wal Out I fl Mors 12.75' 1 WlffawKq.jiObVact2b fmm'lhl Off A-, 61PmaWnlatft x 10 1; irtlhlrne change DA GPH. 6. TLsthckrl + It 7, GMWr&W-hoW km = 0.9 'GPH (if 0.05galbaslhi3w. or �A, tank, passedj Norte; No. pm*q Ol spmimg all"p PeLarg. 4600 q)R. d6 N 4LIN -IJ, ylblR f.'20 Pill T ll-hf�tL - '41 QP63 0 tJME - 7 306 HF I - 46-. 4 L3RT VOL = obf;Ls, TEIIIP HES 77.0 DEG F END,