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Home My WebLink AboutMO-9485_40926_CA_UST-61_20190523_24-Hour Release and UST Leak Reporting FormUST-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 _4527 Incident # Risk (H,I,L,U) Confirmed GW Contamination? (Y/N) _N Date Leak Discovered _5/22/19 Received On Received By Confirmed Soil Contamination ?(Y/N) _Y Comm/Non-Commercial? _Comm_ Reported by (circle one): Phone, Fax or Report Samples Taken?(Y/N) _Y Reg/Non-regulated? _Reg Region Free Product? (Y/N) _N If Yes, State Greatest Thickness INCIDENT DESCRIPTION Incident Name: Circle K 2708383 Address: 873 Old Charlotte Road SW County: Cabarrus City/Town: Concord Zip Code: 28262 Regional Office (circle one): Ashe ' e, Mooresville, etteville, Raleigh, Washington, Wilmington, Wins on- a em Latitude (decimal degrees): 35.4088 Longitude (decimal degrees) :-80.5795 Obtained by: X❑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 discovered during closure of UST system. All tanks/piping/dispensers removed. Soil laboratory analytical results within pit and line trench 5/22/19 indicated elevated TPH-GRO. Over -excavation performed to top of rock 12-16 ft BGS, groundwater not observed. Removed approximately 100-tons soil. Amount of release unknown, no free product observed. No sensitive receptors identified. UST Pit 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) SOURCE OF CONTAMINATION Source of Release Cause of Release Tvpe of Release Product Type Released (Check primary source) (Check primary cause) (Check one) (Check primary product type released) ® Tank ❑ Spill X❑ Petroleum X❑ Gasoline/ Diesel/ ❑ Diesel/Veg. Oil ❑ Piping ❑ Overfill ❑ Non -Petroleum Kerosene Blend Heating Oil ❑ Vegetable Oil 100% ❑❑ Dispenser Corrosion Both ❑❑ ❑ ❑ Other Petroleum E10 — E20Physical/Mechanical ❑ Submersible Turbine Pump ❑ Products Damage Location ❑ E21 — E84 ❑ Delivery Problem (Check one) Metals ❑ ❑ Install Problem ❑ E85 — E99 ❑ Spill Bucket ❑ Other Inorganics ❑ Other X❑Facility ❑Ethanol 100% ❑ Other ❑ Other Organics X❑ Unknown ❑Residence ❑ E01 — E09 El Unknown ❑Other Definitions presented on reverse Definitions presented on reverse Ownership 1. Municipal 2. Military 3. Unkno 4. Private 5. deral 6. County 7. State Operation Type 1. Public Service 2. Agricultural 3. Residential 4. Education/Relig. 5. Industrial [ Commercial . Mining UST Form 61 (02/19) Page 1 of 2 IMPACT ON DRINKING WATER SUPPLIES Water Supply Wells Affected? 1. Yes 2. No 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 Circle K Stores, Inc. Point of Contact Address Debrah Carl 2550 West Tyvola Road, Suite 200 City Charlotte State Zip Code Telephone Number NC 28217 704-583-5762 I UST SYSTEM OPERATOR I UST Operator/Company Address Circle K Stores, Inc. 2550 West Tyvola Road, Suite 200 City Charlotte State Zip Code Telephone Number NC 28217 704-583-5700 LANDOWNER AT LOCATION OF UST INCIDENT I Landowner Address Hickory Woods, Inc. PO Box 526 City State Zip Code Telephone Number Concord NC 28026 N/A I Draw Sketch of Area (showing two major road intersections) or Attach Map Person Reporting Incident Aaron Williamson Company Crawford Environmental Services, Inc. Telephone Number704-909-2911 Title Project Manager Address 301 McCullough Drive, Suite 400, Charlotte, NC 28262 Date 5/23/19 UST Form 61 (02/19) 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 '",q Body Shopwe .0ad outhwes `yRps kv •r � 6 oo le •S: .,tit,. It - L Beverly, Trudy From: Sent: To: Subject: Aaron, Thanks for the update. Trudy DEC QNQRTH GARpL.INA i Department of Environmental Duality Beverly, Beverly, Trudy Monday, June 10, 2019 11:11 AM Aaron Williamson RE: [External] 24-hr Release UST-61 Tle i*, Lam. Mzw Aem4pmm NeA Cmbf Dqwhrmut dEwimmved QIk, OT kown, Xoml1tk offin J�rt ''Yp ess you verify. Send all suspicious email as an .�� . awr WOW Av:ir Ffi i �',r.p �,;f: iS:.or..•.,i'.t,;� i(; i 'iiii ►.};: - ,. , The 20-Day report should be going out the door today. The IAA report will follow within the next couple weeks. Aaron R. Williamson I Project Manager I awilliamson@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 CRAWFO�RUNVIROXMENTAL ERYIEi) 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. From: Beverly, Trudy <trudy.beverly@ncdenr.gov> Sent: Wednesday, May 29, 2019 11:37 AM To: Aaron Williamson <awilliamson@crawfordenvironmental.com> Subject: RE: [External] 24-hr Release UST-61 Aaron, We will need a paper copy and pdf copy on cd for our files. Trudy From: Aaron Williamson [mailto:awilliamson(@crawfordenvironmental.com Sent: Wednesday, May 29, 2019 11:32 AM To: Beverly, Trudy <trudy.beverly@ncdenr.gov> Subject: RE: [External] 24-hr Release UST-61 • External email. Do not click links or open attachments unless you verify. Send all suspicious email as an chment to report.spam@nc.gov Could the 20-day data be submitted by email? We have results from the initial samples, but over excavation sample results are not yet available. Aaron R. Williamson I Project Manager I awilliamson(a@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 R^MFORD WROMME iTAL SERVICES 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. From: Beverly, Trudy <trudy.beverly@ncdenr.gov> Sent: Wednesday, May 29, 2019 10:42 AM To: Aaron Williamson <awilliamson@crawfordenvironmental.com> Subject: RE: [External] 24-hr Release UST-61 Aaron, Since you discovered soil contamination on the property, a new incident number will be generated. An Initial Abatement Report is required. Please send in the lab data as soon as it is available along with a site/sample location map. The map and sample data will be sufficient for the 20 day requirement. Document Submittal & UST File Names for Laserfiche Policies: https://files.nc. gov/ncdeq/Waste%20Management/DWM/TJST/Corrective%2OAction/Electronic%2ODocument%2OSubmittal %20Memo%2OUpdate.pdf hiips:Hfiles.nc. gov/ncdeq/Waste%20Management/DWM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLas erfiche.docx Thanks, Trudy Tle x*-, Lam. D E*0z" m QLOT Orookes �� yr NnRY'N CARnI INA &cdoo, Momudk 1iffim Department at Environmental quality Ci"23S-21 /.wW TrLk* ai�'iEr �F Email correspondence to and from tNs address is subject to ti;e North Carolina Public Records Law and may be disclosed io third ,C aib, .�, Office Mailing Address: 610 East Center Avenue, Suite 301 Mooresville, NC 28115 Branch's Underground Storage Tanks Website Address: https://deq.nc.gov/about/divisions/waste-management/ust Branch's Above Ground Storage Tanks Website Address: https://deq.nc.,gov/about/divisions/waste-management/ust/ast- program INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES: hLtps:Hdeq.nc.gov/about/divisions/waste-management/waste-management-rules-data/waste-mana eg ment- isg maps 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): htt2s:Hedocs.deq.nc.aov/WasteManagement/Search.asp Document Submittal & UST File Names for Laserfiche Policies: https:Hfiles.nc. gov/ncdeq/Waste%20Management/DWM/UST/Corrective%2OAction/Electronic%2ODocument%2OSubmittal %20Memo%2OUpdate.pdf hLtps:Hfiles.nc. gov/ncdeq/Waste%20Management/DWM/UST/Corrective%2OAction/UST%2Ofile%20names%20for%2OLas erfiche.docx From: Aaron Williamson Imailto:awilliamson(@crawfordenvironmental.com Sent: Wednesday, May 29, 2019 8:19 AM To: Beverly, Trudy <trudy.beverly@ncdenr.gov> Subject: RE: [External] 24-hr Release UST-61 • " External email. Do not cli ttachments unless you verify. Send all suspicious email as an tachment to report.spam@nc.gov Thank you for reaching out. I will address the IAA/UST closure report to you. Is the 20-day report also required? Looking at the history of the site, it appears there have been prior releases so now I am wondering if the contamination we discovered is from one of those old releases. There is also a NRP for groundwater on file for the site. Will this 24hr report trigger a new incident number, and if so would it be eligible for closure by filing a NRP for both soil and groundwater? Aaron R. Williamson I Project Manager I awilliamson ancrawfordenvironmental.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 CM*)WFOB8 Ii KONMENTAL SERVICES 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. From: Beverly, Trudy <trudy.beverly@ncdenr.gov> Sent: Wednesday, May 29, 2019 8:10 AM To: Aaron Williamson <awilliamson@crawfordenvironmental.com> Cc: Taraban, Ron <ron.taraban@ncdenr.gov> Subject: RE: [External] 24-hr Release UST-61 Good Morning Aaron, Ron forwarded the UST-61 for the Circle K #2708383 located at 873 Old Charlotte Road, Concord, Cabarrus County to my attention. I handle Cabarrus county sites for the UST section. Have a wonderful day, Trudy DEc1le, NORTH CAROLINA Oeparfinent of Environmental quality TIC lks, L. 162" ard",-Aof I� Nenh Codba Mpmunm d varson6u, mewmAk Rqwa am= C" 23S-2l82 (0 TW.B I7iiIfr�101ir Email 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: https: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- rp ogram INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES: https://deg.nc.gov/about/divisions/waste-management/waste-management-rules-data/waste-mane eg ment- ig s maps File Review Procedures: https://deq.nc. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche): hllps:Hedocs.deq.nc.gov/\VasteManagement/Search.asp Document Submittal & UST File Names for Laserfiche Policies: https:Hfiles.nc. gov/ncdeq/Waste%20Management/DWM/UST/Corrective%2OAction/Electronic%2ODocument%2OSubmittal %20Memo%2OUpdate.pdf hgps:Hfiles.nc. gov/ncdeq/Waste%20Management/DWM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLas erfiche.docx From: Taraban, Ron Sent: Tuesday, May 28, 2019 9:24 AM To: Beverly, Trudy <trudy.beverly@ncdenr.gov> Subject: FW: [External] 24-hr Release UST-61 From: Aaron Williamson <awilliamson@crawfordenvironmental.com> Sent: Friday, May 24, 2019 6:41 AM To: Taraban, Ron <ron.taraban@ncdenr.gov> Subject: [External] 24-hr Release UST-61 ��report.spam@nc.gov rnal email. Do not click links or open attachments unless you verify. Send all suspicious email as an Please see attached 24-hour release form for Facility ID 4527. Evidence of a release was discovered during UST closure activities. Aaron R. Williamson I Project Manager I awilliamson(a 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 RMFRRR KVIRORMFNTAL SERVICES 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.