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Home My WebLink AboutMO-9485_40926_CA_UST-3_20190418_UST Permanent Closure FormUST.3 Notice of Intent: UST Permanent Closure or Change -in -Service Return completed form to: STATE USE ONLY The DWM Regional Office located in the area where the facility is located. Also send a copy to the Central Office in Raleigh. i o # Date Received SEE MAP ON THE BACK OF THIS FORM FOR THE CENTRAL AND REGIONAL OFFICE ADDRESSES. INSTRUCTIONS (READ THIS FIRST) Complete and return at least thirty (30) days prior to closure or change -in-service activities. If a Professional Engineer (P.E.) or a Licensed Geologist (L.G.) provides supervision for closure or change -in-service site assessment activities and signs and seals all closure reports then at least a five (5) working days notice is acceptable. Completed UST closure or change -in-service site assessment reports, along with a copy of the UST-2 form, should be submitted to the appropriate Division of Waste Management (DWM) Regional Office within thirty (30) days following closure activities. The UST-2 form should also be submitted to the Central Office in Raleigh so that the status of the tanks may be changed to permanently closed and your tank fee account can be closed out. Note: Tank fees may be due on unregistered tanks. UST closure and change -in-service site assessments must be completed in accordance with the latest version of the Guidelines for Site Checks, Tank Closure and Initial Response. The guidelines can be obtained at http://www.wastenotnc.org/. Note: To close tanks in place you must obtain prior approval from the DWM Regional office located in the region where the facility is located. You must make sure that USTs removed from your property are disposed of properly. When choosing a closure contractor, ask where the tank(s) will be taken for disposal. Usually, USTs are cleaned and cut up for scrap metal. This is dangerous work and must be performed by a qualified company. Tanks disposed of illegally in fields or other dumpsites can leak petroleum products and sludge into the environment. If your tanks are disposed of improperly, you could be held responsible for the cleanup of any environmental damage that occurs. I. OWNERSHIP OF TANKS II. LOCATION Owner Name (Corporation, Individual, Public Agency, or Other Entity) Facility Name or Company Circle K Stores, Inc. Circle K 2708383 Street Address Facility ID # (If known) 1100 Situs Court, Suite 100 00-0-0000004527 City County Street Address Raleigh Wake 873 Old Charlotte Road SW State Zip Code City County Zip Code NC 27606 Concord Cabarrus 28027 Phone Number Email Phone Number 7041-583-5762 dcarl@circlek.com N/A III. CONTACT PERSONNEL Name: Company Name: Job Title: Phone Number: Debrah Carl Circle K Stores, Inc. Environmental Manager 704-583-5762 IV. TANK REMOVAL, CLOSURE IN PLACE, CHANGE -IN SERVICE 1. Contact local fire marshal. 5. Provide a sketch locating piping, tanks and a P.E. or L.G., with all closure site 2. Plan entire closure event. soil sampling locations. assessment reports bearing the signature 6. Submit a closure report in the format of and seal of the P.E. or L.G. If a release has 3. Conduct Site Soil Assessment. UST-12 (including the form UST-2) within not occurred, the supervision, signature or 4. If removing tanks or closing in place, refer to thirty (30) days following the site seal of a P.E. or L.G. is not required. API Publication 2015 Cleaning Petroleum investigation. 8. Keep closure records for three (3) years. Storage Tanks and 1604 Removal and 7. If a release from the tanks has occurred, the Disposal of Used Underground Petroleum site assessment portion of the tank closure Storage Tanks. must be conducted under the supervision of V. WORK TO BE PERFORMED BY Contractor Name: Contractor Company Name: Charles Crawford, III Crawford Environmental Services, Inc. Address: State: Zip Code: Phone No: 1701 Shenandoah Avenue NW, Roanoke VA 24017 540-343-6256 Primary Consultant Name: Primary Consultant Company Name: Consultant Phone No: Aaron Williamson Crawford Environmental Services, Inc. 704-909-2911 VI. TANKS SCHEDULED FOR CLOSURE OR CHANGE -IN-SERVICE Proposed Activit Closure Change -in -Service Removal Abandonment in Place * New Contents Stored Tank ID No. Size in Gallons Last Contents 1 10000 Gasoline, Gas Mix 2 10000 Gasoline, Gas Mix 3 10000 Gasoline, Gas Mix ® ❑ ❑ ❑ ❑ ❑ * Prior written approval to abandon a tank in place must be received from a DWM Regional Office. VII. OWNER OR OWNER'S AUTHORIZED REPRESENTATIVE I understand that I can be held responsible for environmental damage resulting from the improper disposal of my USTs. Print name and official title: Aaron Williamson, Agent for Circle K Stores, Inc. Signature Date Signed SCHEDULED REMOVAL DATE Notify your DWM Regional Office y } 4/18/19 5/20/19 48 hours before this date if scheduled removal date changes UST-3 Rev 1/2019 Beverly, Trudy From: Beverly, Trudy Sent: Monday, April 22, 2019 8:53 AM To: Hunneke, William F Cc: Taraban, Ron Subject: FW: [External] Form UST-3 Notice of Intent Attachments: 4527_Form-UST-3.pdf Good Morning Bill, We were asked to copy you on UST-3 form submittals for tank removals. Please see the attached UST-3 for 3 tank removals (all 10,000 gallon Gasoline, Gas Mix). Facility ID # 00-0-0000004527 Facility Name Circle K 2708383 Address 873 Old Charlotte Road SW, Concord, Cabarrus County Have a wonderful day, Trudy NORTH GAROLINA ` �" Department of Environmental Duality Tle i*-, L.G. L-ST % Ymmntk offin (7" 23S,21i2 (O a halmd"4mv 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: hLtps:Hdeq.nc.gov/about/divisions/waste-mana,gement/ust/ast- program INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES: https://deq.nc.gov/about/divisions/waste-management/waste-management-rules-data/waste-mana eg ment- ig s maps File Review Procedures: hitps: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. eov/ncdea/Waste°/`2OManaizement/DWM/UST/Corrective%2OAction/Electronic%2ODocument°/`2OSubmittal %20Memo%20Update.pdf httns:Hfiles.nc. izov/ncdea/Waste%2OManaizement/DWM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLas erfiche.docx From: Taraban, Ron Sent: Monday, April 22, 2019 8:41 AM To: Beverly, Trudy <trudy.beverly@ncdenr.gov> Subject: FW: [External] Form UST-3 Notice of Intent From: Aaron Williamson <awilliamsonPcrawfordenvironmental.com> Sent: Thursday, April 18, 2019 9:32 AM To: Taraban, Ron <ron.taraban@ncdenr.gov> Cc: Powers, Mark <mark.powers@ncdenr.gov> Subject: [External] Form UST-3 Notice of Intent External email. Do not click links or open attachments u Ftachment to report.spam@nc.gov Please see attached notice of intent for UST closure by removal. Thanks, Aaron R. Williamson I Project Manager I awilliamson o)crawfordenvironmental.com CES I Crawford Environmental Services, Inc. 301 McCullough Dr, Suite 400 1 Charlotte, NC 128262 T. 704 909 2911 1 F. 540 343 6259 1 M. 910 280 2974 Visit us at: www.crawfordenvironmental.com CR^MFOND KVIRONMEKTAL URVICES PLEASE CONSIDER THE ENVIRONMENT BEFORE PRINTING THIS EMAIL. This electronic transmission is directed to its intended recipient only and may contain information that is proprietary and confidential. If you are not the intended recipient, please be advised that any use, disclosure, distribution or copying of this communication or any attachment is strictly prohibited. If you have received this transmission in error, please notify the sender immediately via e-mail or by calling 540.343.6256. Thank you.