MO-9474_0_C_UST-2_20190306

U 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 [phone] fax [phone] 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
[phone]
III. CONTACT PERSONNEL
Contact for Facility:
Job Title:
Phone #:
Mr. Long Huynh
Owner
[phone]
Closure Contractor Name:
Closure Contractor Company:
Address:
Phone #
Steve Risch
Elite Environmental Services
Clover, SC
[phone]
Primary Consultant Name:
Primary Consultant Company:
Address:
Phone #
Ma se S eckner
PM Environmental, Inc.
Knoxville, TN
[phone]
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
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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 [phone] httR.//www.wastenotnc.org/
1/2016