MO-9477_40918_CA_UST-61_20190102_24-Hour Release Reporting Form

UST-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 12/14/2018
Received On Received By
Confirmed Soil Contamination ?(Y/N) Y
and 12/19/2018
Reported by (circle one): Phone, Fax or Report
Samples Taken?(Y/N) Y
Comm/Non-Commercial? Non-Com.
Region
Free Product? (Y/N) N If Yes, State Greatest
Reg/Non-regulated? Non -Regulated
Thickness
INCIDENT DESCRIPTION
Incident Name:
Address: 7400 and 7416 Matthews -Mint Hill Road
County: Mecklenburg
Regional Office (circle one): Asheville, Mooresville, Fayetteville,
City/Town: Mint Hill
Zip Code: 28227
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): 35.175522/35.175833 Longitude (decimal degrees) :-80.653333/-80.653056
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
On 12/14/18 and 12/19/18, two 550 allon heating oil USTs were removed from two UST basins at the Site.
0 GIS Address matching
Suspected releases were identified based on the presence ofpetroleum-like odors corrosion of the tanks and elevated
❑ Other
organic vapors as indicated by field measurements with aphoto-ionization detector. The suspected releases were
❑ Unknown
confirmed upon receipt of analytical data, which indicated the presence of TPH-DRO (up to 10,000 mg/kg) and TPH-GRC
Describe location:
(up to 150 m/k in soil samples collected from beneath the USTs. Impacted soil excavation activities are in progress
at each of the former UST basins. No impacts to receptors are suspected.
HOW RELEASE WAS DISCOVERED (Release code)
(Check one)
❑ Release Detection Equipment or Methods ❑ Visual/Odor ❑ Groundwater Contamination
0 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)
0 Tank ❑ Spill 0 Petroleum ❑ Gasoline/ Diesel/ ❑ Diesel/Veg. Oil
Kerosene Blend
❑ Piping ❑Overfill ❑Non -Petroleum
0 Heating Oil ❑ Vegetable Oil 100%
❑ Dispenser 0 Corrosion ❑ Both ❑ Other Petroleum ❑ E10 — E20
❑ Submersible Turbine Pump ❑ Physical or Mechanical Products
❑
E21 — E84
Damage Location ❑ Metals
❑ Delivery Problem ❑
oE85 — E99
❑ Install Problem (Checkne ) ❑ Other Inorganics
❑ Other ❑ Other ❑ Other Organics ❑ Ethanol 100%
❑Facility
❑ Unknown
❑ Unknown 0 Residence (former) ❑ E01 — E09
Definitions presented on reverse I Definitions presented on reverse I ❑ Other
Ownership
1. Municipal 2. Military 3. Unknown 4. Private-X 5. Federal 6. County 7. State
Operation Type
1. Public Service 2. Agricultural 3. Residential-X 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 2. No 3. Unknown-X
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
Long Wilson Family I LLC
Point of Contact
Address
Robert Michael Long
11311 Cresthill Drive
City
State
Zip Code
Telephone Number
Charlotte
NC
28227
919-491-0310
UST SYSTEM OPERATOR
UST Operator/Company
Address
Unknown
Unknown
City
State
Zip Code
Telephone Number
Unknown
Unknown
Unknown
Unknown
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
Address
Long Wilson Family I LLC
11311 Cresthill Drive
City
State
Zip Code
Telephone Number
Charlotte
NC
28227
919-491-0310
Draw Sketch of Area (showing two major road intersections) or Attach Map
Person Reporting Incident Bo Cappleman
Company Hart & Hickman, PC
ITelephone Number 704-586-0007
Title Due Diligence Manager
Address 2923 S. Tryon St, Ste 100, Charlotte, NC 28203
Date 1/2/2019
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
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

Beverly, Trudy
From: Bo Cappleman <[e-mail]>
Sent: Tuesday, January 8, 2019 10:53 AM
To: Beverly, Trudy
Subject: RE: [External] UST-61 Notification - 7400 and 7416 Matthews -Mint Hill Rd
ernal email. Do not click links or open attachments unless you verified. Send all suspicious email as an
tachment to [e-mail]
Hi Trudy,
I will be sure to send further documentation to you regarding this and future unregulated incidents. Hoping to
have this one resolved relatively quickly!
Thanks!
Bo Cappleman, PG, Due Diligence Manager
Hart & Hickman, PC
2923 S Tryon Street, Suite 100 •Charlotte, NC 28203
Direct: 704-887-4623 • Mobile: [phone]
www.harthickman.com loom
From: Beverly, Trudy <[e-mail]>
Sent: Tuesday, January 8, 2019 9:49 AM
To: Bowser, Daniel P <[e-mail]>; Bo Cappleman <[e-mail]>
Subject: RE: [External] UST-61 Notification - 7400 and 7416 Matthews -Mint Hill Rd
Hey Bo,
Dan forwarded me your email. I handle unregulated incidents in Mecklenburg County. Please send future
documentation on this to my attention. Thanks.
Have a wonderful day,
Trudy
Q2�
o� F+.0 +Nw.4N Gwi
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
North Carolina DepartmentofEnvironment Quality
Underground Storage Tanks Section
Corrective Action Branch
Mooresville Regional Office
[phone] (Office)
Trudv.Beve rlvCa)ncdenr.eov
+yam: Rice. if 'i I di It �i - ?Ji .., •.. d, I-i n-r. aw.
Branch's Underground Storage Tanks Website Address: https://deg.nc.gov/about/divisions/waste-
management/ust

Branch's Above Ground Storage Tanks Website Address: https://deg.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-
gis-maps
File Review Procedures:
https://deg.nc.gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
https://edocs.deg.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%20
for%20Laserfiche.docx
From: Bowser, Daniel P
Sent: Tuesday, January 8, 2019 9:46 AM
To: Beverly, Trudy <[e-mail]>
Subject: FW: [External] UST-61 Notification - 7400 and 7416 Matthews -Mint Hill Rd
Thank you,
Daniel P. Bowser, PG
Hydrogeologist
North Carolina Department of Environmental Quality
Underground Storage Tank Section - Corrective Action Branch
[phone]
dan.bowserancdenr.aov
610 East Center Ave
Suite 301
Mooresville, North Carolina 28115
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.

From: Bo Cappleman <[e-mail]>
Sent: Monday, January 07, 2019 5:18 PM
To: Bowser, Daniel P <[e-mail]>
Subject: [External] UST-61 Notification - 7400 and 7416 Matthews -Mint Hill Rd
• External email. Do not click links or open attachments unless you verified. Send all suspicious email as an
chment to [e-mail]
Dan,
Hope you're doing well and enjoyed the holidays. Please find the attached UST-61 form for releases from two
unregulated heating oil USTs at 7400 and 7416 Matthews -Mint Hill Road in Mint Hill, NC. As noted on the form,
initial abatement activities are underway. It looks like we are now clean in the excavation for UST-1 but have
more to excavate at UST-2. We are likely excavating to below protection of GW MSCCs on this one due to
proposed future grading/redevelopment in this area by a prospective purchaser of the property. The IAA report
is in progress and will be wrapped up soon after excavation is complete. Please let me know if you have any
questions.
Thanks,
Bo Cappleman, PG, Due Diligence Manager
Hart & Hickman, PC
2923 S Tryon Street, Suite 100 •Charlotte, NC 28203
Direct: 704-887-4623 • Mobile: [phone]
www.harthickman.com JUDO