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HomeMy WebLinkAboutMO-9474_0_C_UST-2_20190306U ST'2A Site Investigation Report for Permanent Closure or Change -IN in - KC REGISTERED Service of UST `"'VQ"r °' „o Return completed form to: NC DEQ / DWM / UST SECTION STATE USE ONLY: Facility ID # 1646 MAIL SERVICE CENTER RALEIGH, NC 27699-1646 ATTN: REGISTRATION & PERMITTING Date Received phone (919) 707-8171 fax (919) 715-1117 http://www.wastenotnc.orq/ INSTRUCTIONS READ THIS FIRST) 1. UST permanent closure or change in service must be completed in accordance with the latest version of the Guidelines for Site Checks, Tank Closure and Initial Response and Abatement. The guidelines can be obtained at http://deg.nc.goy/about/divisions/waste-management/waste- management-permit-guidance/underground-storage-tanks-section. 2. Permanent closure: Complete all sections of this form. 3. Change -in-service: Where a UST system will be converted from storing III, IV, and VI a regulated substance to a non -regulated substance, complete sections I, Il, 4. For more than 5 registered UST systems, attach additional forms as needed 5. Tank Fee Refund: An annual tank fee may be refunded for a tank for which a tank fee was not required. An owner or operator must submit a written request and include: (1) contact information, (2) federal identification # or SSN, and (3) a copy of UST-2 form. The annual tank fee will be prorated based on the date of permanent closure. 6. UNREGISTERED USTs use Form UST-26 I. OWNERSHIP OF TANKS II. LOCATION OF TANKS Owner Name (Corporation, Individual, Public Agency, or Other Entity) Facility Name or Company Mr. Long Hu nh Graham Construction Co. Inc Street Address Facility ID # (If known) 5868 Crimson Oak Ct, 00-0-0000025325 City County Street Address Harrisburg Cabarrus 830 Dolly Street NW State Zip Code City County Zip Code NC 28075 Concord Cabarrus 28027 Phone Number Phone Number (704)661-7078 III. CONTACT PERSONNEL Contact for Facility: Job Title: Phone #: Mr. Long Huynh Owner (704) 661-7078 Closure Contractor Name: Closure Contractor Company: Address: Phone # Steve Risch Elite Environmental Services Clover, SC (704) 914-8568 Primary Consultant Name: Primary Consultant Company: Address: Phone # Ma se S eckner PM Environmental, Inc. Knoxville, TN (865) 329-7191 IV. UST INFORMATION FOR REGISTERED UST SYSTEMS V. EXCAVATION CONDITION UNREGISTERED USTs use Form UST-213 Tank ID No. Size in Gallons Last Contents Last Use Date Permanent Close Date Method of Permanent Closure: Indicate REMOVED or enter fill material, such as foam/ Change -in- Service Date Water in excavation Free product Notable odor or visible soil contaminatio concrete/ sand n Yes No Yes No Yes No 001 2000 Gasoline, unk 2/8/2019 REMOVED NA ❑ ® ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ VI. CERTIFICATION I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and all attached documents and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true accurate and complete. Print name and official title of owner or owner's authorized representative Maryse Speckner / Sr. Project Consultant Signature 4 k Date Signed 3/6/2019 NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION 1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE (919) 707-8171 FAX (919) 715-1117 httR.//www.wastenotnc.org/ 1/2016