MO-9458_40898_CA_UST-61_20190425_24-Hour Release and UST Leak Reporting Form

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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 4/24/19
Received On Received By
Confirmed Soil Contamination ?(Y/N) Y
Comm/Non-Commercial? N - omm.
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: Highsmith Residence
Address: 82 Eastcliff Drive SE
County: Cabarrus
City/Town: Concord
Zip Code: 28025
Regional Office (circle one): Asheville, Mooresville Fayetteville,
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): N 35.39389434' Longitude (decimal degrees) : W 80.56126871 °
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 April 15, 2019 JPH results attached)
-No supply wells within 150 feet of source area
-Notice of Residual Petroleum signed by RP to be submitted by week of 4/29/19
-UST to be internally cleaned and filled in place with concrete on 5/8/19
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)
® Tank ❑ Spill ® Petroleum ❑ Gasoline/ Diesel/ ❑ Diesel/Veg. Oil
Kerosene Blend
❑ Piping ❑Overfill ❑Non -Petroleum ® ❑
Heating Oil Vegetable Oil 100%
❑ Dispenser M Corrosion ❑ Both ❑ Other Petroleum ❑ E10 — E20
❑ Submersible Turbine Pump ❑ Physical or Mechanical Products
❑ E21 E84
—
Damage Location ❑ Metals
❑ Delivery Problem ❑ Install Problem (Check one) ❑ Other Inorganics ❑ E85 — E99
❑ Other ❑ Other Organics ❑ Ethanol 100%
❑Other ❑Facility
❑ Unknown
❑ Unknown M Residence ❑ E01 — E09
Definitions presented on reverse I Definitions presented on reverse I ❑ Other
Ownership
1. Municipal 2. Military 3. Unknown 4O. Private 5. Federal 6. County 7. State
Operation Type
1. Public Service 2. AgriculturalO3. Residential 4. Education/Relig. 5. Industrial 6. Commercial 7. Mining
UST Form 61 (02/08) Page 1 of 2

IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected? 1. Yes 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 Andrew B. Highsmith
Point of Contact
Address
82 Eastcliff Drive SE
City
State
Zip Code
Telephone Number
Concord
NC
28025
[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
1 Date 4/25/2019
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 till
lines are excluded.)
Dispenser: includes the dispenser and the equipment used to connect the dispenser to the piping (e.g., a release from a suction pump or from components located above
the shear valve)
Submersible Turbine Pump (STP) Area includes the submersible turbine pump head (typically located in the tank sump), the line leak detector, and the piping that
connects the submersible turbine pump to the tank
Delivery Problem: identifies releases that occurred during product delivery to the tank. (Typical causes associated with this source are spills and overfills.)
Other: serves as the option to use when the release source is known but does not fit into one of the preceding categories (e.g., for releases from vent lines, vapor
recovery lines, and fill lines)
Unknown: identifies releases for which the source has not been determined
Definitions of Causes
Spill: use this cause when a spill occurs (e.g., when the delivery hose is disconnected from the tank fill pipe or when the nozzle is removed from the dispenser)
Overfill: use when an overfill occurs (e.g., overfills may occur from the fill pipe at the tank or when the nozzle fails to shut off at the dispenser)
Physical or Mechanical Damage: use for all types of physical or mechanical damage, except corrosion (e.g., puncture of tank or piping, loose fittings, broken
components, and components that have changed dimension)
Corrosion: use when a metal tank, piping, or other component has a release due to corrosion (e.g., for steel, corrosion takes the form of rust)
Installation Problem: use when the problem is determined to have occurred specifically because the UST system was not installed properly
Other: use this option when the cause is known but does not fit into one of the preceding categories (e.g., putting regulated substances into monitoring wells)
Unknown: use when the cause has not been determined

Meritech Inc.
Environmental Laboratories
Laboratory Certification #165
Client Name', Paragon Environmental Consultants, Inc.
Project Name P-1923
Site Location 82 Eastcliff Drive SE
Report Date 04/24/19
Sample Matrix Soil
Analyst CWL
Total Petroleum Hydrocarbons
Meritech
ID #
Client
Sample ID
Analysis
Performed
Date
Sampled
Date
Extracted
Dilution
Factor
% Dry
Solids
Surrogate
Recovery
Results
(mg/kg)
Date
Analyzed
04171920
T1-7'
3550
04/15/19
04/18/19
10
79%
**
1,210
04/24/19
i
Hydrocarbon, Ranges Units of Measure Sample Weight: DRO=30.Og GRO=10.Og
DRO - 3550/8015C mg/kg
GRO - 5030/;8015C mg/kg TPH Surrogates/Spikes
DRO/3550 Chrysene/Diesel
Reporting Lirnft for 3550 and 5030 = <10.0 mg/kg GRO/5030 Bromochlorobenzene/Gasoline
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/Conc. 5030 Matrix Spike Recovery = N/A
Diesel 40 - 140% 300 ug/ml 5030 Matrix Spike Duplicate Recovery = NIA
Gasoline 70 -130% 40 ug/ml
3550 Lab Spike Recovery = 118%
Surrogate Recovery Acceptance Range/Conc. 3550 Lab Spike Duplicate Recovery = 121 %
Chrysene 40 -140% 100 ug/ml
Bromochlorobenzene 70 - 130% 100 ug/ml 3550 Matrix Spike Recovery = 106%
3550 Matrix Spike Duplicate Recovery = NIA
5030 LCS/LCSD RPD = N/A
5030 MS/MSD RPD = N/A 3550 LCS/LCSD RPD = 2.51
3550 MS/MSD RPD = NIA
RPD Limit = 15 * Surrogate/Spike/RPD exceeds limits.
** Surrogate/Spike diluted out/matrix interference.
TPH 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: Beverly, Trudy
Sent: Thursday, April 25, 2019 2:25 PM
To: Ben Robinson
Subject: RE: [External] Highsmith Residence UST-61
Received.
Trudy
DEQ;NORTH CAROLINA
Department of Environmental quality
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Email ror►wg)ondenc:e to ark-] 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: https://deq.nc.gov/about/divisions/waste-management/ust/ast-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
https://deq.nc.gov/about/divisions/waste-management/waste-management-rules-data/waste-manor eg ment- isgmaps
File Review Procedures:
https://deq. nc.,gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
hlt2s://edocs.deq.nc.lzov/WasteManagement/Search.aspx
Document Submittal & UST File Names for Laserfiche Policies:
hiips:Hfiles.nc. gov/ncdeq/Waste%2OManagement/DWM/UST/Corrective%2OAction/Electronic%2ODocument%2OSubmittal%2OMe
mo%20Update.pdf
https:Hfiles.nc. gov/ncdeq/Waste%20Management/DWM/UST/Corrective%2OAction/UST%2Ofile%20names%20for%2OLaserfiche.d
ocx
From: Ben Robinson[mailto:[e-mail]]
Sent: Thursday, April 25, 2019 1:39 PM
To: Beverly, Trudy <[e-mail]>
Subject: [External] Highsmith Residence UST-61
I email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachm
c. ov
Hello,
please find attached to this e-mail the UST-61 for the Highsmith Residence, located at 82 Eastcliff Drive SE, Concord, NC 28025. Thank
you very much!

Ben Robinson, L.G.
Paragon Environmental Consultants, Inc.