MO-9450_40889_CA_UST-61_20190405_24-Hour Release and UST Leak Reporting Form

UST-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
[phone]
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

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Beverly, Trudy
From: Brandon Moore <[e-mail]>
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:[e-mail]]
Sent: Friday, April 5, 2019 9:48 AM
To: Brandon Moore <[e-mail]>
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:[e-mail]]
Sent: Friday, April 5, 2019 9:40 AM
To: Beverly, Trudy <[e-mail]>
Cc: 'Ben Robinson' <[e-mail]>
Subject: [External] 157 N. Union Street in Concord
[e-mail]
Trudy,
See attached
Brandon Moore
Paragon Environmental Consultants, Inc.
[phone]