MO-9461_40901_CA_UST-61_20190524_24-Hour Release & UST Leak Reporting & Emails

'. U ST.61
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 5/17/19
Received On Received By
Confirmed Soil Contamination ?(Y/N) Y
Comm/Non-Commercial? N n- 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: Gornto Property
Address: 2727 Palm Avenue
County: Mecklenburg
City/Town: Charlotte
Zip Code: 28205
Regional Office (circle one): Asheville, Mooresville Fayetteville,
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): N 35.236085' Longitude (decimal degrees) : W 80.7804950
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 May 8, 2019 JPH results attached)
-No supply wells within 150 feet of source area
-Notice of Residual Petroleum signed by RP to be submitted week of 5/27/19
-UST to be abandoned in -place during early June
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 M 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
❑ ❑ E85 E99
e Other Inorganics —
❑ Install Problem (Check on )
❑ Other ❑ Other Organics ❑ Ethanol 100%
❑Other Facility
❑ Unknown
O unKnown ® F2cafdonco ❑ E01 — E09
Definitions presented on reverse Definitions presented on reverse ❑ Other
Ownership
1. Municipal 2. Military 3. Unknown 4O. Private 5. Federal 6. County 7, State
Operation Tvpe
1. Public Service 2. Agriculturalo Residential 4. Education/Relig. 5. Industrial 6. Commercial 7. Mining
u� i rorm bi tuuua) Page f 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 Paula Faye Gornto
Point of Contact
Address
P. O. Box 9590
City
State
Zip Code
Telephone Number
Charlotte
NC
28299
[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 B. Moore
Company Paragon Environmental Consultants, Inc.
Telephone Number(336) 669-6037
Title Geologist
Address P.O. Box 157, Thomasville, NC 27361
Date 5/24/2019
U51 Form tit (w/u6)
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
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. Report Date 05/14/19
Project Name P-1931 A Sample Matrix Soil
Site Location 2727 Palm Ave. 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
05101901
T1-6'
3550
05/08/19
05/13/19
100
82%
**
16,700
05/13/19
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
DRO13550 Chrysene/Diesel
Reporting Limit 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/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 = 115%
Surrogate Recovery Acceptance Range/Cone. 3550 Lab Spike Duplicate Recovery = 111%
Chrysene 40 - 140% 100 ug/ml
Bromochlorobenzene 70 - 130% 100 ug/ml 3550 Matrix Spike Recovery = 107%
5030 LCS/LCSD RPD = N/A 3550 Matra Spike Duplicate Recovery = NIA
5030 MS/MSD RPD = NIA 3550 LCS/LCSD RPD = 3.54
3550 MS/MSD RPD = N/A
RPD Limit = 15 * Surrogate/Spike/RPD exceeds limits.
* Surrogate/Spike diluted out/matrix interference.
i rn meouri mevision uojuniva
I hereby certify that I have reviewed and approve these data.
Reviewed By

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Beverly, Trudy
From:
Beverly, Trudy
Sent:
Thursday, May 30, 2019 8:20 AM
To:
Brandon Moore
Cc:
'Ben Robinson'
Subject:
RE: [External] UST-61 for 2727 Palm Avenue in Charlotte
Thanks
From: Brandon Moore [mailto:[e-mail]]
Sent: Thursday, May 30, 2019 8:19 AM
To: Beverly, Trudy <[e-mail]>
Cc: 'Ben Robinson' <[e-mail]>
Subject: RE: [External] UST-61 for 2727 Palm Avenue in Charlotte
External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
[e-mail]
550 gallon we believe but it could be a 275 gallon — definitely no larger than a 550 gallon
Brandon
From: Beverly, Trudy [mailto:[e-mail]]
Sent: Thursday, May 30, 2019 7:57 AM
To: Brandon Moore <paragonenv@north state. net>; 'Ben Robinson' <[e-mail]>
Subject: RE: [External] UST-61 for 2727 Palm Avenue in Charlotte
Brandon or Ben,
What is the approximate tank size?
Trudy
From: Brandon Moore [mailto:[e-mail]]
Sent: Wednesday, May 29, 2019 9:26 AM
To: Beverly, Trudy <[e-mail]>
Subject: RE: [External] UST-61 for 2727 Palm Avenue in Charlotte
External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
[e-mail]
Sorry but just sent w/o map as this message came in — you may disregard that version
Brandon
From: Beverly, Trudy [mailto:[e-mail]]
Sent: Wednesday, May 29, 2019 9:25 AM
To: Brandon Moore <[e-mail]>

Cc: 'Ben Robinson' <[e-mail]>; Taraban, Ron <[e-mail]>
Subject: RE: [External] UST-61 for 2727 Palm Avenue in Charlotte
Everything together please.
Trudy
From: Brandon Moore [mailto:[e-mail]]
Sent: Wednesday, May 29, 2019 9:21 AM
To: Beverly, Trudy <[e-mail]>
Cc: 'Ben Robinson' <[e-mail]>; Taraban, Ron <[e-mail]>
Subject: RE: [External] UST-61 for 2727 Palm Avenue in Charlotte
External email. Do not click links or open attachments unle ail as an attachment to
[e-mail]
Thank you
I can forward the NRP signed by Ms. Gornto to you for review: however, the map is not yet completed. Would you like
to see just the text portion of this document now or wait until we have the Figure 1 map showing the location of the soil
contamination to include with it?
Brandon
From: Beverly, Trudy [mailto:[e-mail]]
Sent: Wednesday, May 29, 2019 9:17 AM
To: Brandon Moore <paragonenv@north state. net>
Cc: 'Ben Robinson' <[e-mail]>; Taraban, Ron <[e-mail]>
Subject: RE: [External] UST-61 for 2727 Palm Avenue in Charlotte
Brandon,
Ron is out of the office today and will be out of the office on Friday. He should be in the office tomorrow. Check back in
the morning to confirm.
Trudy
From: Brandon Moore [mailto:[e-mail]]
Sent: Wednesday, May 29, 2019 8:26 AM
To: Beverly, Trudy <[e-mail]>
Cc: 'Ben Robinson' <[e-mail]>
Subject: RE: [External] UST-61 for 2727 Palm Avenue in Charlotte
External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
[e-mail]
Trudy,
Thank you — I have the NRP signed by the RP and will forward to you by email later today for your review
Could we make an appointment for Ben or I to bring this in and have it signed by Ron later this week? The tank is being
abandoned in -place on Tues. (June 4) and we'd like to record it while we will be in Charlotte for the field work part of
this project.

Brandon
From: Beverly, Trudy [mailto:[e-mail]]
Sent: Wednesday, May 29, 2019 7:52 AM
To: Brandon Moore <[e-mail]>
Subject: RE: [External] UST-61 for 2727 Palm Avenue in Charlotte
UST-61 received.
Thank you,
Trudy
Em* Hsralr. L.G.
IQNoIn�Orule a D ream �� 1 Qu ft
LOT �cdoo, � Offim
Department of Environmental Quality C"235-21V (O
EmaR 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: https:Hdeq.nc.gov/about/divisions/waste-management/ust/ast-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httns:Hdeu.nc. eov/about/divisions/waste-management/waste-management-rules-data/waste-management-gis-mans
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):
httDs:Hedocs.dea.nc. izov/WasteManaizement/Search.asnx
Document Submittal & UST File Names for Laserfiche Policies:
https:Hfiles.nc. gov/ncdeq/Waste%20ManagementIDWM/UST/Corrective%2OAction/Electronic%2ODocument%2OSubmittal%2OMe
mo%20Update.pdf
https://files.nc. gov/ncdeq/Waste°/`20Management/DWMIUST/Corrective%2OAction/UST%2Ofile%20names%20for%2OLaserfiche.d
ocx
From: Brandon Moore [mailto:[e-mail]]
Sent: Friday, May 24, 2019 3:42 PM
To: Beverly, Trudy <[e-mail]>
Subject: [External] UST-61 for 2727 Palm Avenue in Charlotte
MT MOL External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
[e-mail]
Trudy,
See attached for this property — the NRP is supposed to be in the mail back to me after having been signed by Ms.
Gornto

I will try to get that NRP to you next week for review and for having Ron to sign it
Thanks,
Brandon Moore
Paragon Environmental Consultants, Inc.
[phone]