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HomeMy WebLinkAboutMO-9450_40889_CA_UST-61_20190405_24-Hour Release and UST Leak Reporting FormUST-61 I 24-Hour Release and UST Leak Reporting Form. For Releases This form should be completed and submitted to the UST Section's regional office following a known or suspected release from an underground storage tank (UST) system. This form is required to be submitted within 24 hours of discovery of a known or in NC suspected release (DWM USE ONLY) Suspected Contamination? (Y/N) Y Facility ID Number N/A Incident # Risk (H,I,L,U) Confirmed GW Contamination? (Y/N) N Date Leak Discovered 4/4/19 Received On Received By Confirmed Soil Contamination ?(Y/N) Y Comm/Non-Commercial? Non- mm. Reported by (circle one): Phone, Fax or Report Samples Taken?(Y/N) Y Reg/Non-regulated? Non -Reg. Region Free Product? (Y/N) N If Yes, State Greatest Thickness N/A INCIDENT DESCRIPTION Incident Name: Perugini Property Address: 157 N. Union Street County: Cabarrus city/Town: Concord Zip Code: 28025 Regional Office (circle one): Asheville, Mooresville Fayetteville, Raleigh, Washington, Wilmington, Winston-Salem Latitude (decimal degrees): N 35.41436643' Longitude (decimal degrees) : W 80.586071720 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 Describe location: -Soil contamination confirmed by laboratory result for soil sample collected by hand auger on March 26, 2019 TPH results attached -No supply wells within 150 feet of source area -Notice of Residual Petroleum signed by RP to be submitted by week of 4/8/19 -UST to be removed during week of 4/8/19 HOW RELEASE WAS DISCOVERED (Release code) (Check one) ❑ Release Detection Equipment or Methods ❑ Visual/Odor ❑ Groundwater Contamination ❑ During UST Closure/Removal ❑ Water in Tank ❑ Surface Water Contamination ❑ Property Transfer ❑ Water Supply Well Contamination ® other (specify) hand auger SOURCE OF CONTAMINATION Source of Release Cause of Release Type of Release Product Type Released (Check one to indicate primary (Check one to indicate primary (Check one) (Check one to indicate primary product type source) cause) released) M Tank ❑ Spill M Petroleum ❑ Gasoline/ Diesel/ ❑ Diesel/Veg. Oil Kerosene Blend ❑ Piping ❑ Overfill ❑ Non -Petroleum ® ❑ Heating Oil Vegetable Oil 100% ❑ Dispenser ® Corrosion ❑ Both ❑ Other Petroleum ❑ El — E20 ❑ Submersible Turbine Pump ❑ Physical or Mechanical Products ❑ Damage Location ❑ Metals E21 — E84 ❑ Delivery Problem ❑ (Check one) ❑ Other Inorganics E85 — E99 ❑Install Problem ❑ Other ❑ Other Organics ❑ Ethanol 100% Other Facility ❑ Unknown 0 Unknown ® Rasidanna ❑ E01 — E09 Definitions presented on reverse Definitions presented on reverse ❑ Other Ownership 1. Municipal 2. Military 3. Unknown 0Private 5. Federal 6. County 7. State Operation Type 1. Public Service 2. AgriculturalO3. Residential 4. Education/Relig. 5. Industrial 6. Commercial 7. Mining uz:) i rorm bi tuuua/ Page 1 of 2 IMPACT ON DRINKING WATER SUPPLIES Water Supply Wells Affected? 1. Yes ONo 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 Danielle A. Perugini Point of Contact Address 201 Scalybark Trail City State Zip Code Telephone Number Concord NC 28027 (631) 235-9787 UST SYSTEM OPERATOR UST Operator/Company Address Unknown City State Zip Code Telephone Number LANDOWNER AT LOCATION OF UST INCIDENT Landowner Same as UST System Owner Address City State Zip Code Telephone Number Draw Sketch of Area (showing two major road intersections) or Attach Map See Attached Map Person Reporting Incident Ben Robinson Company Paragon Environmental Consultants, InC. Telephone Number(336) 669-6037 Title Geologist Address P.O. Box 157, Thomasville, NC 27361 Date 4/5/2019 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 Dennitions or 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 offat 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 Meritech Inc. Environmental Laboratories Laboratory Certification #165 Client Name _Paragon Environmental Consultants, Inc. Report Date 04/04/19 Project Name P-1917 Sample Matrix Soil Site Location 167 Union Street North Analyst CWL Total Petroleum Hydrocarbons Meritech ID # Client Sample ID Analysis Performed Date Sampled Date Extracted Dilution Factor % Dry Solids Surrogate Recovery Results m /k Date Analyzed 03281904 T1-6' 3550 03/26/19 04/02/19 100 81% "` 12,700 04/03/19 Hydrocarbon Ranges Units of Measure Sample Weight: DRO=30.Og GRO=10.Og DRO - 355018015C mg/kg GRO - 5030/8015C mg/kg TPH Surrogates/Spikes DRO/3550 Chrysene/Diesel Reporting Limit for 3550 and 5030 = <10.0 mg/kg GRO/5030 Bromochlorobenzene/Gasoiine Was method blank below reporting limit? 5030 Lab Spike Recovery = N/A (YES) NO - Details Attached 5030 Lab Spike Duplicate Recovery = N/A Spike Recovery Acceptance Range/Cone, 5030 Matrix Spike Recovery = N/A Diesel 40 - 140% 300 ug/ml 5030 Matrix Spike Duplicate Recovery = N/A Gasoline 70 - 130% 40 ug/ml 3550 Lab Spike Recovery = 121 % Surrogate Recovery Acceptance Range/Cone. 3550 Lab Spike Duplicate Recovery = 107% Chrysene 40 -140% 100 ug/ml Bromochlorobenzene 70 -130% 100 ug/ml 3550 Matrix Spike Recovery = ** 3550 Matrix Spike Duplicate Recovery = N/A 5030 LCS/LCSD RPD = N/A 5030 MS/MSD RPD = N/A 3550 LCS/LCSD RPD = 12.3 3550 MS/MSD RPD = N/A RPD Limit = 15 ` Surrogate/Spike/RPD exceeds limits. "* Surrogate/Spike diluted out/matrix interference. i PH Report Revision 05/05/09 I hereby certify that I have reviewed and approve these data. Reviewed By r c d CL d o o Cc, VI m v J c y a v d E bZ H H s-v v T x a U -, N w o Q Z d z �° 'O aCL O 'c° •.� � � � E U- LLJ LL v v oLn C 4 Q Q cu �, 3 IV L Y c v c ` O uj T Q �`• oCd ld ? 7ca"VEi �'^}oy`ONng• Em 72r � cu Y n a m m a UO OtU/7yc m CL N Q 12 LLO Q m Z N W o .a) U zz cr c = a 7 c i 4— LLJ Tt •ice LL O W � _Q VI CF) 0I +-j C/) C: 0 C ZD r- LO r— AAC M ;,, ',A b 0 col O > E 2 a', 43 'r, C,ti 0"C) 00- 75) 0 C,4 Beverly, Trudy From: Brandon Moore <paragonenv@northstate.net> Sent: Friday, April 5, 2019 9:57 AM To: Beverly, Trudy Subject: RE: [External] 157 N. Union Street in Concord Wml)nc.gov ternal email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to Thank you From: Beverly, Trudy [mailto:trudy.beverly@ncdenr.gov] Sent: Friday, April 5, 2019 9:48 AM To: Brandon Moore <paragonenv@northstate.net> Subject: RE: [External] 157 N. Union Street in Concord Received. Trudy TIC x*-, Lam. RE Q rvoan I caRol <, Il JF LOT &-cliso, Momudl : Rq*md Offim OWarbngnt of Environmental nuality Email correspondence to and from this address is subject to the North Carolina Public Records Law and may be disclosed to third parties. Office Mailing Address: 610 East Center Avenue, Suite 301 Mooresville, NC 28115 Branch's Underground Storage Tanks Website Address: h!Ws:Hdeq.nc.gov/about/divisions/waste-management/ust Branch's Above Ground Storage Tanks Website Address: hLps://deq.nc.gov/about/divisions/waste-management/ust/ast-program INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES: https:Hdeg.nc.gov/about/divisions/waste-management/waste-management-rules-data/waste-mana eg ment ig s-maps File Review Procedures: hLps://deq.nc. gov/about/divisions/waste-management/ustlfile-review-procedures#mooresville-regional-office ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche): https:Hedocs.deq.nc.gov/WasteManagement/Search.asp Document Submittal & UST File Names for Lasenfiche Policies: https://files.nc. gov/ncdeq/Waste%20Mana,gementIDWM/UST/Corrective%20Action/Electronic%20Document%20Submittal%20Me mo%20Update.pdf hops://files.nc. gov/ncdeq/Waste%20Management/DWM/UST/Corrective%20Action/UST%20file%20names%20for%20Laserfiche.d ocx From: Brandon Moore [mailto:paragonenv@northstate.net] Sent: Friday, April 5, 2019 9:40 AM To: Beverly, Trudy <trudy.beverly@ncdenr.gov> Cc: 'Ben Robinson' <brobinson8915@gmail.com> Subject: [External] 157 N. Union Street in Concord report.spam@nc.gov Trudy, See attached Brandon Moore Paragon Environmental Consultants, Inc. (336) 669-6037