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Home My WebLink AboutMO-9464_40904_CA_UST-61_20190228_24-Hour Release and UST Leak Reporting Formb. i:n a '' µr�4 7 �� H ,t, _... ?=Hour Rland UST.rl ' 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) Incident p Risk (H,I,L,U) Suspected Contamination?QVN) Confirmed GW Contamination? Y Facility ID Number Date Leak iscovered iS Received On Received By ---_ Confirmed Soil Contamination ( /N) Com on- o Reported by (circle one): Phone, Fax or Report ...... Samples TakenloYN) Reg on -re Mate ---------- -------- Region -_—__ Free Product? (Y! --- If Yes, Slate Greatest Thickness INCIDENT DESCRIPTION Incident Name: Address: 1 L.• �op ` County: Crily/Town: ,�'_'�Q `` Zip Code: Regional Office (circle one): Asheville, VDore Fa teville, Raleigh, Wilmington, Winston-Salem /Washington. Latitude,(d.d.W dog—): Sf l,�oZJu�r i Longitude (AecinuM noy e«a) : S; 1� 01-' = 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 U Unknown Describe location: HOW RELEAS WAS DISCOVER D (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) 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 Cl Petroleum ❑ Gasoline/ Diesel/ ❑ DieselNeg. oil Kerosene Blend ❑ Piping ❑Overfill UNDn-Petroleum ❑ Hosting Oil Vegetable Oil 100% ❑ Dispenser Corrosion ❑ Both U Other Petroleum ❑ E10-E20 ❑ Submersible Turbine Pump ❑ Physical or Mechanical Products ❑ E21 E84 - ❑ Delivery Problem Damage Location ❑ Metals ❑ Install Problem (Check one) ❑ Other Inorganics ❑ E85 - E99 ❑ Other ❑ Other ❑ Other Organics ❑ Ethanol 100% ❑Facility ❑ Unknown ❑ Unknown NO Residence ❑ E01 - E09 Definitions presented on reverse I Definitions presented on reverse I ❑ Other Ownership 1. Municipal 2. Military 3. Unknown 4.' rival 5. Federal 6. County 7. State Operation Type 1. Public Service 2. Agricultural 3. iden ' 1 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 \�Oo 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. J.'-NfN 3. UST SYSTEM OWNER UST Owner/Comp Mit, Point of Contact Address City 7to Zip Code Telephone Number UST SYSTEM OPERATOR UST Operator/Company Address City --i,41ateN Zip Code Telephone Number LANDOWNER AT LOCATION OF UST INCIDENT Landowner Address City State Zip Code Telephone Number Draw Sketch of Area (showing two major road intersections) or Attach Map C CY N L" 1) k Person Reporting Incident Company I'4;�o j Telephone Number Title Co q �\ Address (.. a 'o Z "" -L_ 23 111 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 producl delivery to the tank. (Typical causes associated with this sourer urc spills and uvertill..s Other: serves as the option to use when the release source is known but du;6 not tit into one of the preceding categories (e.g., for releases from vent Imes, 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 (ill pipe or when the nozzle is removed from the dispenser) Overfill: use when an overfill occurs (e.g., overfills may occur from the fill pipe at the tank or when the nozzle fails to shut off at the dispenser) Physical or Mechanical Damage: use for all types of physical or mechanical damage, except corrosion (e.g., puncture of tank or piping, loose fittings, broken components, and components that have changed dimension) Corrosion: use when a metal tank, piping, or other component has a release due to corrosion (e.g., for steel, corrosion takes the form of rust) Installation Problem: use when the problem is determined to have occurred specifically because the UST system was not installed properly Other: use this option when the cause is known but does not fit into one of the preceding categories (e.g., putting regulated substances into monitoring wells) Unknown: use when the cause has not been determined Beverly, Trudy From: Beverly, Trudy Sent: Monday, March 4, 2019 6:32 AM To: rro@inencoinc.com' Subject: RE: [External] 24 HR Notice Kushner 3416 Little Hope Rd Ryan, If you have had to over excavate, all samples would need to be analyzed by risk based standards. Trudy DE NnRTH CARC7l.INA i Department of Environmental Duality TI Bad. L.S. WNW Afffloaff ffia QUAY 4AT Sadim MomIli Rapigad Ofte P7M 711-711111117 (Mm) Email correspondence to and from this address is subiect 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: hllps:Hdeq.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-mane eg ment- ig s maps File Review Procedures: https:Hdeq.nc. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche): hltps:Hedocs.deq.nc.aov/WasteManagement/Search.asp Document Submittal & UST File Names for Laserfiche Policies: httDs:Hfiles.nc. izov/ncdea/Waste%20Manaizement/DWM/UST/Corrective%20Action/Electronic%20Document%20Submittal %20Memo%20Update.pdf https://files.nc. eov/ncdea/Waste%20Manaeement/DWMIUST/Corrective%20Action/UST%20file%20names%20for%20Las erfiche.docx From: rro@inencoinc.com [mailto:rro@inencoinc.com] Sent: Friday, March 1, 2019 12:20 PM To: Beverly, Trudy <trudy.beverly@ncdenr.gov> Subject: RE: [External] 24 HR Notice Kushner 3416 Little Hope Rd External email. Do not click links or open attachments unless you verify. Send all suspicious email as an t to report.spam@nc.gov Trudy, I hope that you are not out of the office today and in the crappy weather! I have a question about the soil sampling for the Kushner property. (Home heating Oil UST) I collected five soil samples (one bottom sample and four sidewall samples) after we completed the excavation. I prepped all of the samples for the "Risk -Based" analysis methods, but have not delivered them to the laboratory, yet. In the past I have been able to limit the number of samples that were analyzed by the "Risk -Based" analysis methods. If I recall correctly, we have closed sites with DRO/GRO samples for the side walls and risk based for the bottom sample. The client is looking for a No Further Action letter. Can you give me some direction in this matter? Please give me a call if that works better for you. Thank You! Ryan R. Osborne, PE INENCO, Inc. 132 W. Statesville Ave. Mooresville, NC 28115 Office: 704-662-8192 Fax: 704-662-8194 Mobile: 336-978-4725 Note: Please be sure that rro@inencoinc.com is the email address you are using for me. From: Beverly, Trudy <trudy.beverly@ncdenr.gov> Sent: Thursday, February 28, 2019 8:51 AM To: Steve Hamilton <smhamilton@comporium.net> Cc: tim@cert-usa.com; tgummel@simonini.com; Ryan Osborne <rro@inencoinc.com> Subject: RE: [External] 24 HR Notice Kushner 3416 Little Hope Rd Got it. Thank you, Trudy DE NORTH CARO!_INA � Deperhnent of Environmental Quality Tl Bad. L.S. W IdwWaff fflu QUAY UT Sedim Mamn6O Radnd Office rim 291-310 (C m) Email correspondence to and from this address is subject4o 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: https://deq.nc.lzov/about/divisions/waste-mana�zement/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://deg.nc. gov/about/divisions/waste-management/waste-management-rules-data/waste-management-ais-mates File Review Procedures: https://deq.nc. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche): https:Hedocs.deq.nc.,gov/WasteManagement/Search.aspx Document Submittal & UST File Names for Laserfiche Policies: https://files.nc. gov/ncdeq/Waste%20Management/DWM/UST/Corrective%20Action/Electronic%20Document%20Submittal %20Memo%20Update.pdf https://files.nc.gov/ncdeq/Waste%20Management/DWM/UST/Corrective%20Action/UST%20file%20names%20for%20Las erfiche.docx From: Steve Hamilton[mailto:smhamilton@comporium.net] Sent: Thursday, February 28, 2019 8:37 AM To: Beverly, Trudy <trudy.beverly@ncdenr.gov> Cc: tim@cert-usa.com; tgummel@simonini.com; Ryan Osborne <rro@inencoinc.com> Subject: [External] 24 HR Notice Kushner 3416 Little Hope Rd External email. Do not click links or open attachments unless you verify. Sen attachment to report.spam@nc.gov Trudy Beverly NCDEQ Trudy, Attached please find the 24 HR Notice for Kushner Property at 3416 Little Hope Rd. Charlotte, NC. Regards, Steve Steve Hamilton- Consultant C.E.R.T. Carolina Environmental Response Team PO Box 681016 Charlotte, NC 28216 704-309-4262 cell 877-505-6799 office CONFIDENTIALITY NOTICE: This e-mail communication, including any attachments, may contain privileged or confidential information for specific individuals and is protected by law. If you are not the intended recipient(s), you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited and you should delete this message and its attachments from your computer without retaining any copies. If you have received this communication in error, please reply to the sender immediately. We appreciate your cooperation. 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