MO-7444_36096_CA_UST-61_20190820_24-Hour Release and UST Leak 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)
Incident # Risk (H,I,L,U)
Suspected Contamination? (Y/N) Y
Confirmed GW Contamination? (Y/N)
Facility ID Number 00-0-0000011084
Date Leak Discovered 8/20/19
Received On Received By
Reported by (circle one): Phone, Fax or Report
Confirmed Soil Contamination ?(Y/N) Y
Samples Taken?(Y/N) Y
Comm/Non-Commercial? Comm
Reg/Non-regulated? Reg
Region
Free Product? (Y/N) N If Yes, State Greatest
Thickness
INCIDENT DESCRIPTION
Incident Name:
Pilot Travel Centers 056
Address: 2825 Lane Street
County: Cabarrus
City/Town: Kannapolis Zip Code: 28081
Regional Office (circle one): Ashevill Mooresville, ayetteville,
Raleigh, Washington, Wilmington, Winston- a em
Latitude (decimal degrees): 35 29'53.20" N Longitude (decimal degrees) : 80 33' 39.54"W Obtained by:
Briefly describe suspected or confirmed release: (including but not limited to: nature of release, date of release, amount
of release, amount free ❑
of product present and recovery efforts, initial responses conducted, impacts to rece tors) GPS
❑Topographic map
Laboratory analytical results of a Soil sample collected adjacent to diesel dispenser #20 at a ept o rve eet
XGIS Address matching
bgs detected a TPH-DRO value in exceed of the State Action Level of 100 mg/kg. These activities were ❑Other
conducted as per the Notice of Violation dated June 5, 2019. A Site Check Report is being prepared. ❑ Unknown
Describe location:
HOW RELEASE WAS DISCOVERED (Release code)
(Check one)
❑Release Detection Equipment or Methods ❑Visual/Odor ❑Groundwater Contamination
El 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 Tvpe Released
(Check primary source) (Check primary cause) (Check one (Check primary product type released)
09
❑ Tank El spill Petroleum Gasoline/ Diesel/ ❑ Diesel/Veg. Oil
❑ Piping ❑ Overfill ❑ Non -Petroleum Kerosene Blend
Dispenser ❑ Corrosion ❑ Both ❑ Heating Oil ❑ Vegetable Oil 100%
❑ Submersible Turbine Pump ❑ Physical/Mechanical ❑ Other Petroleum ❑ E10 — E20
Damage Location Products
❑ Delivery Problem g ❑ E21 — E84
(Check one) ❑ Metals
❑ Install Problem
❑ Spill Bucket ❑ E85 — E99
❑ Other ❑Other Facility ❑Other Inorganics
El Ethanol 100%
,Unknown ❑Residence ❑Other Organics
❑ Unknown ❑ E01 — E09
❑Other
Definitions presented on reverse Definitions presented on reverse
Ownership
1. Municipal 2. Military 3. Unknown 4. Private . Federal 6. County 7. State
Operation Tvpe
1. Public Service 2. Agricultural 3. Residential 4. Education/Relig. 5. Industria 6. Commercia 7. Mining
UST Form 61 (02/191
Page 1 of 2

IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected? 1. Yes 2. No 3. Unknow
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
Pilot Travel Centers, LLC
Point of Contact
Address
Keith Carlton, Environmental Project Manager
5508 Lonas Road
City
State
Zip Code
Telephone Number
Knoxville
TN
37909
864-474-3106
UST SYSTEM OPERATOR
UST Operator/Company
Address
Pilot Travel Centers, LLC
5508 Lonas Road
City
State
Zip Code
Telephone Number
Knoxville
TN
37909
864-474-3106
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
Address
Pilot Travel Centers, LLC
5508 Lonas Road
City
State
Zip Code
Telephone Number
Knoxville
TN
37909
864-474-3106
Draw Sketch of Area (showing two major road intersections) or Attach Map
See attached site map
Person Reporting Incident M. Jackson
Company ATC Associates of NC (on behalf of Pilot)
Telephone Number 919-561-3893
Title PG/Sr. Project Manager
IAddress 609A Piner Rd, Suite 115 Wilmington, NC 28409
Date 8/20/2019
VV on 11 V 1 kv4/ 1U)
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 till
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 tit 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 tit into one of the preceding categories (e.g., putting regulated substances into monitoring wells)
Unknown: use when the cause has not been determined

m
DIESEL FUEL ' W
DISPENSER ISLAND m' N
(TYPICAL) E = o
#24
z
L
0
#23 o Q
V
>- o
a y
0
F
#22} •� 1
a 11
(n z
Z Z
UJI
--E _ a o Q
#21 0
SB-1 I;
w_
2PAVED
PAVED
--E
#19
-E-�1-
#18
--------------------- #17
GRASS
z
DUMPSTERS � J
L O
LANDSCAPED PILOT CL-
U
TRAVEL CENTER z w
LJ
#56 GRASS U z
cw�
CN L,j
� Ld � Qo
�cl-
PAVED W ~ Z
Li � N
PAVED
GASOLINE
DISPENSING
CANOPY
LEGEND: 0 30 60
W
• = SOIL SAMPLE APPROXIMATE SCALE IN FEET z

�FaceAnalytical o ANALYTICAL REPORT
National Center for Testing & Innovation August 19, 2019
FTC
FS
ATC Group Services - NC Pilot I
Sample Delivery Group: L1127728 [Cn]
Samples Received: 08/10/2019 FrProject Number: 56-605-13
Description: Pilot 56 RC
GI
Report To: Maureen Jackson
609A Piner Road Suite 115 rzl
Wilmington, NC 28409
FC
Entire Report Reviewed By
Jeff Carr
Project Manager
Results relate only to the items tested or calibrated and are reported as rounded values. This test report shall not be
reproduced, except in full, without written approval of the laboratory. Where applicable, sampling conducted by Pace
Analytical National is performed per guidance provided in laboratory standard operating procedures ENV-SOP-MTJL-0067 and
ENV-SOP-MTJL-0068. Where sampling conducted by the customer, results relate to the accuracy of the information provided,
and as the samples are received.
I a
ACCOUNT: PROJECT: SDG: DATE/TIME: PAGE:
ATC Group Services - NC Pilot 56-605-13 L1127728 08/19/19 17:16 1 of 11

TABLE OF CONTENTS
ONE LAB. NATIONWIDE.
Cp: Cover Page
1
Fn
Tc: Table of Contents
2
Ss: Sample Summary
3
Cn: Case Narrative
4
Sr: Sample Results
5
FS
SB-1 L1127728-01
5
[Cn]
Qc: Quality Control Summary
6
Total Solids by Method 2540 G-2011
6
Fr
Volatile Organic Compounds (GC) by Method 8015D/GRO
7
Semi -Volatile Organic Compounds (GC) by Method 8015C
8
RC
Gl: Glossary of Terms
9
F
Al: Accreditations & Locations
10
Sc: Sample Chain of Custody
11
rAl
FSC
ACCOUNT: PROJECT: SDG:
DATE/TIME: PAGE:
ATC Group Services - INC Pilot 56-605-13 L1127728
08/19/19 17:16 2 of 11

SAMPLE SUMMARY ONE LAB. NATIONWIDE.
Collected by Collected date/time Received date/time
S13-1 L1127728-01 Solid Austen Rubenstein 08/09/1911:15 08/10/19 09:00 C
P
Method
Batch Dilution Preparation Analysis
date/time date/time
Analyst Location
Total Solids by Method 2540 G-2011
WG1330214
1 08/19/19 09:52
08/19/19 09:58 KBC
Mt. Juliet, TN
Volatile Organic Compounds (GC) by Method 8015D/GRO
WG1330422
25 08/09/1911:15
08/17/1919:09 ACG
Mt. Juliet, TN
Semi -Volatile Organic Compounds (GC) by Method 8015C
WG1329660
20 08/16/1916:01
08/19/19 01:57 KME
Mt. Juliet, TN
ACCOUNT:
PROJECT:
SDG:
DATE/TIME:
ATC Group Services - INC Pilot
56-605-13
L1127728
08/19/19 17:16
PAGE:
3 of 11
FTC
M
[Cn]
FSr
RC
F,
FAI
FSC

CASE NARRATIVE
ONE LAB. NATIONWIDE.
FP1
All sample aliquots were received at the correct temperature, in the proper containers, with the
appropriate preservatives, and within method specified holding times, unless qualified or notated within
the report. Where applicable, all MDL (LOD) and RDL (LOQ) values reported for environmental samples
FTChave
been corrected for the dilution factor used in the analysis. All Method and Batch Quality Control
are within established criteria except where addressed in this case narrative, a non-conformance form
or properly qualified within the sample results. By my digital signature below, I affirm to the best of my
FSS
knowledge, all problems/anomalies observed by the laboratory as having the potential to affect the
quality of the data have been identified by the laboratory, and no information or data have been
knowingly withheld that would affect the quality of the data.
FSr
Fc
�
GI
Jeff Carr
Project Manager
FAI
FSC
ACCOUNT: PROJECT: SDG: DATE/TIME:
PAGE:
ATC Group Services - INC Pilot 56-605-13 L1127728 08/19/19 17:16
4 of 11

SB-1
Collected date/time: 08/09/19 11:15
Total Solids by Method 2540 G-2011
SAMPLE RESULTS - 01
L1127728
Result Qualifier Dilution Analysis Batch
Analyte % date / time
Total Solids 85.2 1 08/19/2019 09:58 WG1330214
Volatile Organic Compounds (GC) by Method 8015D/GRO
Result (dry) Qualifier MDL (dry) RDL (dry)
Dilution Analysis Batch
Analyte
mg/kg
mg/kg mg/kg
date/time
TPH (GC/FID) Low Fraction
48.7
0.636 2.94
25 08/17/201919:09 WG1330422
(S)
a, a, a- Trifluorotoluene(FID)
91.7
77.0-120
081771201919:09 WG1330422
Semi -Volatile Organic Compounds
(GC) by Method 8015C
Result (dry) Qualifier MDL (dry) RDL (dry) Dilution Analysis Batch
Analyte mg/kg mg/kg mg/kg date/time
TPH (GC/FID) High Fraction 4890
(S) o-Terphenyl 0.000
18.1 93.9 20 08/19/2019 01:57 WG1329660
J7 18.0-148 0811912019 01:57 WG1329660
ONE LAB. NATIONWIDE.
FP1
FTC
FSS
4
Cn
6
QC
7G1
FAI
FSC
ACCOUNT: PROJECT: SDG: DATE/TIME: PAGE:
ATC Group Services - INC Pilot 56-605-13 L1127728 08/19/19 17:16 5 of 11

WG1330214
Total Solids by Method 2540 G-2011
Method Blank (MB)
(MB) R3441897-1 08/19/19 09:58
MB Result MB Qualifier MB MDL
Analyte % %
Total Solids 0.000
L1127738-01 Original Sample (OS) • Duplicate (DUP)
MB RDL
(OS) L1127738-01 08/19/19 09:58 • (DUP) R3441897-3 08/19/19 09:58
Original Result DUP Result Dilution DUP RPD
Analyte % % _ %
Total Solids 82.4 82.5 1 0.113
Laboratory Control Sample (LCS)
(LCS) R3441897-2 08/19/19 09:58
Spike Amount LCS Result LCS Rec.
Analyte % %_ %
Total Solids 50.0 50.0 100
QUALITY CONTROL SUMMARY
L1127728-01
DUP Qualifier DUP RPD
Limits
10
Rec. Limits LCS Qualifier
o/
85.0-115
ONE LAB. NATIONWIDE.
- I
Cp
FTc
FSS
4
— Cn
FSr
— 7G1
FAI
[Sc
ACCOUNT: PROJECT: SDG: DATE/TIME: PAGE:
ATC Group Services - NC Pilot 56-605-13 L1127728 08/19/19 17:16 6 of 11

WG1330422
Volatile Organic Compounds (GC) by Method 8015D/GRO
Method Blank (MB)
QUALITY CONTROL SUMMARY
L1127728-01
(MB) R3441600-2 08/17/1912:43
MB Result MB Qualifier MB MDL
MB RDL
Analyte
mg/kg mg/kg
mg/kg
TPH (GC/FID) Low Fraction
0.0256 J 0.0217
0.100
(S)
o, o, o-Trifluorotoluene(FID)
93.7
77.0-120
Laboratory Control Sample (LCS)
(LCS) R3441600-1 08/17/1911:18
Spike Amount LCS Result LCS Rec. Rec. Limits LCS Qualifier
Analyte mg/kg mg/kg % %
TPH (GC/FID) Low Fraction 5.50 5.59 102 72.0-127
(S) 104 77.0-120
a, a, a- Trifluorotoluene(FID)
L1127738-14 Original Sample (OS) • Matrix Spike (MS) • Matrix Spike Duplicate (MSD)
(OS) L1127738-14 08/17/19 20:31 • (MS) R3441600-3 08/17/19 20:51 • (MSD) R3441600-4 08/17/19 21:12
Spike Amount Original Result MS Result MSD Result MS Rec. MSD Rec.
Analyte mg/kg mg/kg mg/kg mg/kg % %
TPH (GC/FID) Low Fraction 5.50 0.988 112 109 76.1 74.4
(S) 102 101
a, a, a- Trifluorotoluene(FID)
Dilution Rec. Limits MS Qualifier MSD Qualifier RPD
26.5 10.0-151 2.26
77.0-120
ONE LAB. NATIONWIDE.
RPD Limits
28
FP1
FTc
FSS
H
5
Sr
7G1
FAI
[Sc
ACCOUNT: PROJECT: SDG: DATE/TIME: PAGE:
ATC Group Services - NC Pilot 56-605-13 L1127728 08/19/19 17:16 7 of 11

WG1329660
Semi -Volatile Organic Compounds (GC) by Method 8015C
Method Blank (MB)
(MB) R3441376-1 08/16/19 23:22
MB Result MB Qualifier MB MDL MB RDL
Analyte mg/kg mg/kg mg/kg
TPH (GC/FID) High Fraction U 0.769 4.00
(S) o-Terpheny/ 64.0 18.0-148
Laboratory Control Sample (LCS)
I
QUALITY CONTROL SUMMARY
L1127728-01
(LCS) R3441376-2 08/16/19 23:35
Spike Amount LCS Result LCS Rec. Rec. Limits LCS Qualifier
Analyte mg/kg mg/kg % %
TPH (GC/FID) High Fraction 50.0 27.6 55.2 50.0-150
(S) o-Terpheny/ 67.1 18.0-148
ONE LAB. NATIONWIDE.
FP1
FTC
FSS
4
Cn
s
Sr
7G1
FAI
[SC
ACCOUNT: PROJECT: SDG: DATE/TIME: PAGE:
ATC Group Services - NC Pilot 56-605-13 L1127728 08/19/19 17:16 8 of 11

GLOSSARY OF TERMS
ONE LAB. NATIONWIDE.
Guide to Reading and Understanding Your Laboratory Report
The information below is designed to better explain the various terms used in your report of analytical results from the Laboratory. This is not
intended as a comprehensive explanation, and if you have additional questions please contact your project representative.
Results Disclaimer - Information that may be provided by the customer, and contained within this report, include Permit Limits, Project Name,
Sample ID, Sample Matrix, Sample Preservation, Field Blanks, Field Spikes, Field Duplicates, On -Site Data, Sampling Collection Dates/Times, and
Sampling Location. Results relate to the accuracy of this information provided, and as the samples are received.
Abbreviations and Definitions
(dry) Results are reported based on the dry weight of the sample. [this will only be present on a dry report basis for soils].
MDL Method Detection Limit.
MDL (dry) Method Detection Limit.
RDL Reported Detection Limit.
RDL (dry) Reported Detection Limit.
Rec. Recovery.
RPD Relative Percent Difference.
SDG Sample Delivery Group.
Surrogate (Surrogate Standard) - Analytes added to every blank, sample, Laboratory Control Sample/Duplicate and
(S) Matrix Spike/Duplicate; used to evaluate analytical efficiency by measuring recovery. Surrogates are not expected to be
detected in all environmental media.
U Not detected at the Reporting Limit (or MDL where applicable).
Analyte The name of the particular compound or analysis performed. Some Analyses and Methods will have multiple analytes
reported.
If the sample matrix contains an interfering material, the sample preparation volume or weight values differ from the
Dilution standard, or if concentrations of analytes in the sample are higher than the highest limit of concentration that the
laboratory can accurately report, the sample may be diluted for analysis. If a value different than 1 is used in this field, the
result reported has already been corrected for this factor.
These are the target % recovery ranges or % difference value that the laboratory has historically determined as normal
Limits for the method and analyte being reported. Successful QC Sample analysis will target all analytes recovered or
duplicated within these ranges.
Original Sample The non -spiked sample in the prep batch used to determine the Relative Percent Difference (RPD) from a quality control
sample. The Original Sample may not be included within the reported SDG.
This column provides a letter and/or number designation that corresponds to additional information concerning the result
Qualifier reported. If a Qualifier is present, a definition per Qualifier is provided within the Glossary and Definitions page and
potentially a discussion of possible implications of the Qualifier in the Case Narrative if applicable.
The actual analytical final result (corrected for any sample specific characteristics) reported for your sample. If there was
no measurable result returned for a specific analyte, the result in this column may state "ND" (Not Detected) or "BDL"
Result (Below Detectable Levels). The information in the results column should always be accompanied by either an MDL
(Method Detection Limit) or RDL (Reporting Detection Limit) that defines the lowest value that the laboratory could detect
or report for this analyte.
Uncertainty Confidence level of 2 sigma.
(Radiochemistry)
A brief discussion about the included sample results, including a discussion of any non -conformances to protocol
Case Narrative (Cn) observed either at sample receipt by the laboratory from the field or during the analytical process. If present, there will
be a section in the Case Narrative to discuss the meaning of any data qualifiers used in the report.
Quality Control This section of the report includes the results of the laboratory quality control analyses required by procedure or
Summary (Qc) analytical methods to assist in evaluating the validity of the results reported for your samples. These analyses are not
being performed on your samples typically, but on laboratory generated material.
This is the document created in the field when your samples were initially collected. This is used to verify the time and
Sample Chain of date of collection, the person collecting the samples, and the analyses that the laboratory is requested to perform. This
Custody (Sc) chain of custody also documents all persons (excluding commercial shippers) that have had control or possession of the
samples from the time of collection until delivery to the laboratory for analysis.
This section of your report will provide the results of all testing performed on your samples. These results are provided
Sample Results (Sr) by sample ID and are separated by the analyses performed on each sample. The header line of each analysis section for
each sample will provide the name and method number for the analysis reported.
Sample Summary (Ss) This section of the Analytical Report defines the specific analyses performed for each sample ID, including the dates and
times of preparation and/or analysis.
Qualifier Description
J The identification of the analyte is acceptable; the reported value is an estimate.
J7 Surrogate recovery cannot be used for control limit evaluation due to dilution.
ACCOUNT: PROJECT: SDG: DATE/TIME: PAGE:
ATC Group Services - INC Pilot 56-605-13 L1127728 08/19/19 17:16 9 of 11
FP1
FTC
FSS
[Cn]
FSr
FC-1
$AI
FSC

ACCREDITATIONS & LOCATIONS ONE LAB. NATIONWIDE.
Pace National is the only environmental laboratory accredited/certified to support your work nationwide from one location. One phone call, one point of contact, one laboratory. No other lab is as
accessible or prepared to handle your needs throughout the country. Our capacity and capability from our single location laboratory is comparable to the collective totals of the network
laboratories in our industry. The most significant benefit to our one location design is the design of our laboratory campus. The model is conducive to accelerated productivity, decreasing FP1
turn -around time, and preventing cross contamination, thus protecting sample integrity. Our focus on premium quality and prompt service allows us to be YOUR LAB OF CHOICE.
Not all certifications held by the laboratory are applicable to the results reported in the attached report.
Accreditation is only applicable to the test methods specified on each scope of accreditation held by Pace National. Z
Tc
State Accreditations
f—�
Alabama
40660
Nebraska _
NE-OS-15-05
SS
Alaska
17-026
Nevada
TN-03-2002-34
Arizona
AZO612
New Hampshire
2975
Arkansas
88-0469
New Jersey_NELAP
TNO02
C n
California
2932
New Mexico
n/a
Colorado
TN00003
New York
11742
s
Connecticut
PH-0197
North Carolina
Env375
Sr
Florida
E87487
North Carolina'
DW21704
Georgia
NELAP
North Carolina'
41
Georgia'
923
North Dakota
R-140
RC
Idaho
TN00003
Ohio—VAP
CL0069
Illinois
200008
Oklahoma
9915
Indiana
C-TN-01
Oregon
TN200002
G
Iowa
364
Pennsylvania
68-02979
Kansas
E-10277
Rhode Island
LA000356
Kentucky76
90010
South Carolina
84004
Kentucky 2
16
South Dakota
n/a
Louisiana
A130792
Tennessee' 4
2006
Louisiana'
LA180010
Texas
T104704245-18-15
[SC
Maine
TN0002
Texas'
LABO152
Maryland
324
Utah
Massachusetts
M-TNO03
Vermont
Michigan
9958
Virginia
Minnesota
047-999-395
Washington
Mississippi
TN00003
West Virginia
Missouri
340
Wisconsin
Montana
CERT0086
Wyoming
Third Party
Federal Accreditations
A21LA — ISO 17025
1461.01
AIHA-LAP,LLC EMLAP
A21LA — ISO 17025 5
1461.02
DOD
Canada
1461.01
USDA
EPA—Crypto
TN00003
' Drinking Water 'Underground
Storage Tanks 3 Aquatic Toxicity 4 Chemical/Microbiological 5 Mold
6 Wastewater n/a Accreditation not applicable
Our Locations
TN00003
VT2006
460132
C847
233
9980939910
A2LA
100789
1461.01
P330-15-00234
Pace National has sixty-four client support centers that provide sample pickup and/or the delivery of sampling supplies. If you would like assistance from one of our support offices, please contact
our main office. Pace National performs all testing at our central laboratory.
WA
ME
MT NO
OR MN
T ID t WI NY
SD
WY MI
NV
t NE IA OH PA
T f IL Ills WV
vA
UT T
CA�� T
KS MO KY
N
NM O� AR SC
T MS AL`7GA
T TX * LA
T
AK
q FL
wo HI
ACCOUNT: PROJECT: SDG: DATE/TIME: PAGE:
ATC Group Services - NC Pilot 56-605-13 L1127728 08/19/19 17:16 10 of 11

ATC Group Services - NC Pilot
609A Piner Road Suite 115
Billing Informatiorc
Melody Mayville P'cs
5508 Lonas Dr. Chk
Knoxville, TN 37909
Analysis/Container/Preservative
Chain of Custody Page J_of I
ceAnalyical"'
Wilmington, NC 28409
_
°1
�_
11o65 LeM1anBd Q Q
Mount lulleont iN 311"
Phone. 63s-]sssese
Phone. e00]6]-6859
ra�.61s-]seses9
Rep ort to.
Maureen Jackson
Emad To: [e-mail]
Project
Description: Pilot 56
City/State •'
Collected. l�annaPpl tSi !'' L
#
I�Z7
T 8212
Phone:[phone]
Fax:
Client Project #
56-605-13
lab Project It
PILOTATCWNC-56
Z
N
�O
O
a
O
a0
Z
O
O
l7
v,
O
2
`
-)
c
"N
N
t—
Aa.,.,,. n . rILOTATCW NC
Template:T153734
Prel°gin: P722123
TSR: 206 -Jeff Carr
PB. -( -
Collected by (print):
�����✓ - ,
Site/Facility ID #
P.O. #
PILOT KANNAPOLIS
Collected by (signature :
t
Immediately .`,//
Packed on Ice N _ Y X
Rush? (Lab MUST Be Notified Quote (1
_ Same Day Five Day Sf
_ Next Day _ 5 Day (Bad Only) Date Results Needed
Two Day _10 Day (Rod Only) No.
_Three Day of
Shipped via: FedEX Ground
Sample ID
Comp/Grab
Matrix •
Depth
Date
nits
Time
acm..k: sample x Ilah nmvl
S/3—�
C71 S
SS
14
g/9 19
it 15 15
x
x
x
- of
)
I
i
emarks: Re por f 1—
N C 0 EQ VjT /eafLj pH Temp
Flow Other
Samples returned via:
-0 G 5
_UPS )<FedEx _Courier Tracking# 110? 9n 15 6 796
• Matrix:
SS -Soil AIR - Air F- Filter
GW- Groundwater B-Bioassay
WW-Waste Water
DW- Drinking Water
OT - Other
Sampl� Receipt
co: Seal Present/Intact: _NP _N
COC Signed/Accurate: _rY _N
Bottles arrive intact: nY N
Correct bottles used: �Y N
Sufficient volume sent: h _N
If AoolicaDle
VOA Zero Headspace:
,/Y _N
Preservation Correct/Checked: _Y _N
p
RAD SCREEN: <0.5 m"
Relinqui hed by: ignature)
�i9TC
Date:
g/i/Z019
Time:
J�oo
Received by: (Signature)
g
Trip Blank Received: Ye No
p T RL/ Me0"
Relinquished by: (Signature)
Date:
Time:
Received by: (Signature)
Temp: °C Battles Recel ed.
If preservation required by Login: Date/Time
Relinquished by: (Signature)
Date:
Time:
Received fo ab by: (Sign ture)
Date: Time:
Hold:
Condition:
NCF / 6(y

Beverly, Trudy
From: Maureen Jackson <[e-mail]>
Sent: Tuesday, August 20, 2019 1:06 PM
To: Beverly, Trudy; Taraban, Ron
Cc: Richard Stevens
Subject: RE: [External] Pilot 56 24-Hour Release Notice
External email. Do not click links or open attachments unless you verify. Send
attachment to [e-mail]
Thank you!
Maureen Jackson I SENIOR PROJECT MANAGER I ATC Group Services LLC
[phone]
609A Piner Road Suite 115 1 Wilmington, NC 28409
maureen.jackson@atc-s� I www.atcgroupservices.com
This email and its attachments may contain confidential and/or privileged information for the sole use of the intended recipient(s). If
you are not the intended recipient, any use, distribution or copying of the information contained in this email and its attachments is
strictly prohibited. If you have received this email in error, please notify the sender by replying to this message and immediately
delete and destroy any copies of this email and any attachments. The views or opinions expressed are the author's own and may not
reflect the views or opinions of ATC.
From: Beverly, Trudy [mailto:[e-mail]]
Sent: Tuesday, August 20, 2019 1:04 PM
To: Taraban, Ron <[e-mail]>; Maureen Jackson <[e-mail]>
Subject: RE: [External] Pilot 56 24-Hour Release Notice
Hi Maureen,
Thank you for submitting the 24-Hour Release form for Pilot 56 in Kannapolis. I am the project manager for UST
sites in Cabarrus County. Please direct future communications related to the release to my attention.
Thank you,
Trudy
N4Fi7'li CArarll.:,�l�1
ddpYlVrltN 81 EIYrFfQrM16lc1nl 4ud'� ly
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
North Carolina Department of Environmental Quality
UST Section, Mooresville Regional Office
704.235.2182 (Office)
Trudy.Beverlygncdenr. gov
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: hns://deq.nc.gov/about/divisions/waste-management/ust

Branch's Above Ground Storage Tanks Website Address: https://dea.nc.gov/about/divisions/waste-mana2ement/ust/ast-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
hit2s:Hdeg.nc.gov/about/divisions/waste-management/waste-management-rules-data/waste-mana 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):
httns://edocs.dea.nc. gov/WasteManagement/Search.asnx
Document Submittal & UST File Names for Laserfiche Policies:
htips:Hfiles.nc.gov/ncdegfWaste%20Management/DWM/ JST/Corrective%2OAction/Electronic%2ODocument%2OSubniittal%2OMemo%2OUpdate.pdf
https:Hfiles.nc. gov/ncdeq/Waste%20Management/DWM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx
From: Taraban, Ron
Sent: Tuesday, August 20, 2019 12:57 PM
To: Beverly, Trudy <[e-mail]>
Subject: FW: [External] Pilot 56 24-Hour Release Notice
From: Maureen Jackson <[e-mail]>
Sent: Tuesday, August 20, 2019 12:49 PM
To: Taraban, Ron <[e-mail]>; Stutts, Jack L <[e-mail]>
Subject: [External] Pilot 56 24-Hour Release Notice
External email. Do not click links or open attachments unless you verify. Send all suspicious email as an
t to [e-mail]
Good afternoon. A 24-Hour Release notice is attached for Pilot 56 in Kannapolis, NC
Thanks
Maureen Jackson I SENIOR PROJECT MANAGER I ATC Group Services LLC
[phone]
609A Piner Road Suite 115 1 Wilmington, NC 28409
[e-mail] I www.atcgroupservices.com
This email and its attachments may contain confidential and/or privileged information for the sole use of the intended recipient(s). If
you are not the intended recipient, any use, distribution or copying of the information contained in this email and its attachments is
strictly prohibited. If you have received this email in error, please notify the sender by replying to this message and immediately
delete and destroy any copies of this email and any attachments. The views or opinions expressed are the author's own and may not
reflect the views or opinions of ATC.