MO-7444_36096_G_C_20190821_Diesel Pump #20 Emails

Beverly, Trudy
From:
Beverly, Trudy
Sent:
Wednesday, August 21, 2019 10:59 AM
To:
Maureen Jackson
Cc:
Richard Stevens
Subject: RE: [External] Pilot 56 Requested Information
Thank you Maureen.
Trudy
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
irmv..,ow-D
North Carolina Department of Environmental Quality
UST Section, Mooresville Regional Office
S;WrLnenl Gmn-on mental4w
704.235.2182 (Office)
Trudy. B everlykncdenn 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: https://deg.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:
https://deq.ne.gov/about/divisions/waste-management/waste-management-rules-data/waste-mana eg ment ig s=maps
File Review Procedures:
hops: //deq.ne. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
hops://edocs.deq.nc. gov/WasteManagement/Search.aspxx
Document Submittal & UST File Names for Laserfiche Policies:
htips:Hfiles.nc. gov/ncdeq/Waste%20Mana,gemenUD WMIUST/Corrective%2OActionBlectronic%2ODocument%2OSubnuttal%2OMemo%2OUpdate.pdf
ht!Rs:Hfiles.nc. gov/ncdeq/Waste%20Management/DWM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx
From: Maureen Jackson [mailto:[e-mail]]
Sent: Wednesday, August 21, 2019 10:57 AM
To: Beverly, Trudy <[e-mail]>
Cc: Richard Stevens <[e-mail]>
Subject: [External] Pilot 56 Requested Information
MM • External email. Do not click links or open attachments unless you verify. Send all suspicious email as an
achment to [e-mail]
Good morning. Per our earlier conversation, please find attached the requested NOV and repair documentation
as we discussed.
Thanks
Maureen

Maureen Jackson i SENIOR PROJECT MANAGER I ATC Group Services LLC
[phone]
609A Piner Road Suite 115 1 Wilmington, NC 28409
maureen.iackson@atc_sq com 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.

•,® CT Corporation
TO: Ki istisTl K Seabrook, AttorneyAb
Picot Travel CRrQrs LLC
5508 La-nas Dr
Knoxville, TN 37909-3221
• • • • • •
RE: Process Served in North Carolina
rave e(DO` )
Strvice of Proces o
Transmittal rlllll�i`
06/10/2019
CT Lob Member 535641592
• • • • • • • • • • •
ENCLOSED ARE COFi OF LEGAL PROCESS RECEIVED BY THE STATUTORY AGENT CIF THE ABOVE COMPANY AS FOLLOWS:
WDOCUMENT(S) SERVED:
NOTICE, AWCN'iw'ENT(S)
,COURT/AGENCY.,
None Specif Rd
Case # Nome Specified
NATURE OF AC4000
Code Violation / Code E.nforcerwerk - Violation: FailsirR to meet the overfill control
requirements of a 'nev# ' as tanks stemrequired by federal regulation
oN WHOM PROCESS WAS SERVED:
T Corporation wstem. Rateieh.
7TE AND HOI�R OF 8ER"'CE
yj �Qa on 01 postmar a on 06/05/2019RISDICTIC�N
SERVED,
North Carolina
APPEARANCE OR ANSWER 11 iE:
Within 30 days of receipt of this notice
f"TTORNEY(S) I SENDEIIi
Jack Stutts, Erwironmental Specialist
North Carolina Diapartment cf Environritental Quality - Division of Waste
Management
1646 Mail service en er
NC 2;�S
•Raleigh,
A IaN I E S,
CT "••as retained the current log, Retain Date: 06/10/2019, Expected Pmrge Date:
06/15/2019
Ira:aga SAP
E,maR Netification, Kristin K Seabrook [e-mail].,mo
SIGNED:
CT Corporatiom System
D E ,
160 MME LAKE CT STE 2�Q
Raleigh, NC 27615 -
TELEPHONE:
954-473-5503
Page 1 of 1 / RK
information lisplayed on this transmittal is fsr CT
Corporations recorl keepfing purposes wily and is provided is
the recipient for quick reference. This fnformatbon does not
utu�re constitute a legal opinion as to the nof action, the
amount of damages, the answer date, or any information
contained fin the documents themselves. Recipient is
responsftQle for finterpreting said documents and for t
appropriate action. Signatares on certified mail receipts
confirm receipt of package only, not coFtevts. _

NORTH CAROLINA DEPARTMENT OF
r.� ENVIRONMENTAL QUALITY
DIVISION OF WASTE MANAGEMENT
1646 MAIL SERVICE CENTER
Environmental RALEIGH, NORTH CAROLINA 27699-1646
Quality
111111111111111II
.i
-,�$7.600 ME
U5 POSTAGE
FIRST-CLASS
FROM 28212
JUN 05 2019
starnt
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CT Corporation System, Registered Agent
Pilot Travel Centers, LLC
160 Mlne Lake Ct Ste 20.0
Raleigh NC 27615-6417

ROY COOPER
t io+rmur
MICHAEL S. REGAN
Sermlor),
MICHAEL SCOTT
INFLIClor
CERTIFIED MAIL 70I81130000228216448
RETURN RECEIPT REQUESTED
CT Corporation System, Registered Agent
Pilot Travel Centers, LLC
160 Mine Lake Ct Ste 200
Raleigh, NC 27615-6417
NORTH CAROLINA
Environmental Quality
June 05, 2019
Re: NOTICE Of VIOLATION OF ISA NCAC 2N .030I(UPG3), .0603(RLS5, RLS3),
Pilot Travel Centers 056
2825 Lane Street, Kannapolis, NC 28081
Cabarrus County
Facility ID#: 00-0-0000011084
Dear CT Corporation System:
On June 05, 2019, 1 conducted a compliance inspection at the above -referenced facility. I observed that
underground storage tanks (USTs) at Pilot Travel Centers 056 are not in compliance with North Carolina UST
regulations (North Carolina Administrative Code [NCAC] 2N "Criteria and Standards Applicable to Underground
Storage Tanks). According to those rules (15A NCAC 2N .0203) Pilot Travel Centers, LLC'is identified as the
owner and/or operator of UST(s) at Pilot Travel Centers 056.
The following violations of the state rules (I SA NCAC 2N) were observed on June 05, 2019 at Pilot Travel Centers
056. Following each violation are the actions required to correct the violations:
Violation 1: 15A NCAC 2N .0301 UPG3; Failure to meet the overfill control requirements of a 'new tank system'
as required by federal regulation 40 CFR 280.20(c) (as incorporated by 15A NCAC 2N .0301).
Corrective Action(s)-
All UST systems installed after December 22, 1988 are defined as 'new tank systems.' All "new tank systems" that
are filled by transfers of more than 25 gallons at one time are required to have overfill control equipment. Please
complete one of the following actions:
1) The overfill prevention equipment was inspected however the equipment is not installed at the correct height in
the tank or it needs repairing and does not meet the performance standards of 15A NCAC 2N .0301. Provide
documentation, on a UST-22A form, Overfill Prevention Equipment Operability Check, of an operability check
conducted in accordance with the manufacture's written guidelines, PEI RP 1200 "Recommended Practice for the
Testing and Verification of Spill, Overfill, Leak Detection and Secondary Containment Equipment at US'r
Facilities" and the instructions on the UST-22A form.
Submit a copy of invoices, designs or other documentation, such as a letter signed by the installer or a report from an
equipment contractor, of the completed work within 30 days of receipt of this notice to the inspector at the address
provided. In addition, if overfill control is added, please submit a UST-8 form Notification for Activities Involving
USTs identifying methods (i.e., automatic shut-off device or overfill alarm) used and provide documentation of an
operability check on a UST-22A form, Overfill Prevention Equipment Operability Check.
Comment: Tank #A1 - DIESEL, Tank #132 - PREMIUM, Tank #C3 - REGULAR, Tank #D DIESEL 1, Tank
#E DIESEL 2: The submitted UST-22A form, dated November 16, 2018, lists all overfill equipment as
passing. However, the data on the form does not meet the criteria of a passing inspection. Conduct a
DEQ>
"� Mfq,pRapf pgKry-
North Carolina Department or Fnvironmenial Quality I Division or waste Management
217 Rest Jones Start 11646111ail Service Cenler I Raleigh, North Carolina 27699-1646
919.707.8171

new overfill equipment operability check and submit the revised form to the inspector.
Violation 2: 15A NCAC 2N .0603 RLS5; Failure to investigate a suspected release in accordance with federal
regulation 40 CFR 280.52 (as incorporated by 15A NCAC 2N .0603) after an unusual operating condition has
been observed. ("Unusual operating conditions" include, but are not limited to, the erratic behavior of
dispensing equipment; the unexplained presence of water in the tank; the presence of fuel in containment sumps
or interstitial spaces; or the degradation of any equipment or element of an underground storage tank system to
the point where that equipment or element can not reasonably be expected to perform its intended function.).
Corrective Aetion(s):
Tank owners or operators must investigate a suspected release as directed below.
1) Empty* and clean the containment sumps and/or under dispenser containment. Investigate cause and repair the
components that caused the release of liquid to the containment sumps.
2) Conduct a tightness test of the containment sump(s) integrity in accordance with the manufacturer's
recommendations* or a code of practice developed by a nationally recognized association. If a testing standard is not
available then you must fill the containment sump(s) with clean water above all piping and conduit penetrations;
mark the water level; wait a minimum of 3 hours and re -check the level. A containment sump fails the tightness test
if there has been any change in level. Submit a copy of the test results to the inspector at the address provided. If any
containment sump fails the tightness test, you must complete all of the following tasks: (a) Conduct a site check
around the areas listed above in accordance with 40 CFR 280.52(b) (as incorporated by 15A NCAC 2N .0603) using
the sampling protocol and methodology of the most recent version of the UST Section Guidelines for Site Checks,
Tank Closure, and Initial Response and Abatement and submit , within 30 days of receipt of this notice, a site check
report or initial abatement report (whichever is applicable) to the inspector at the address provided; AND (b) Repair
or replace the containment sump and test the tightness of the containment sump in accordance with the
manufacturer's recommendations, a code of practice developed by a nationally recognized association, or the
alternate instructions listed above if no standard is available. If the containment sump is replaced as part of this
repair then the containment sump must meet the secondary containment requirements of 15A NCAC 2N .0900.
Within 30 days of receipt of this notice submit a UST-178, UST Suspected Release 7 Day Notice, with the results
and any supporting information for all equipment repairs, equipment replacements, tightness test(s), and site check
as required in the above sections to the inspector at the address provided. * Proper disposal of liquids in accordance
with State and Federal requirements is required. See the attached document "Recommended ways to dispose of
small quantities of petroleum and petroleum/water mixtures" for some suggested methods.
Comment: Dispenser ND20: Empty and clean the listed under dispenser containment sump. Conduct a tightness
test of the sump. If the tightness test fails conduct a site check.Submit all testing results to the inspector.
Violation 3: 15A NCAC 2N .0603 RLS3; Failure to investigate a suspected release in accordance with federal
regulation 40 CFR 280.52 (as incorporated by 15A NCAC 2N .0603) after an unusual operating condition has
been observed such as fuel weeps from equipment at dispensers or tank tops.
Correctivc Aclion(s):
1) Small weeps from components under the dispenscr(s) and/or at the tank top(s) were observed. Within 7 days of
receipt of this notice, investigate the cause and repair the components that caused the fuel weeps and submit a UST-
1713, UST Suspected Relcase 7 Day Notice, with documentation of the repairs attached, to the inspector.
Comment: Dispenser #D20: Investigate the cause and repair the components that caused the fuel weep.
Notice of Deficiency:
Deficiency 1: NCGS 143-215.94NN-SS OPTR4; Failure to maintain compliance with UST regulations which
requires Primary Operator retraining as required by NCGS 143-215.94NN - 143.215.94SS.
Corrective Action[s):
Please perform the following corrective action:
1) Within 30 days of receipt of this notice, the Primary Operator designated for this facility must go to the following
website http://tankschool.nc.gov and register for one of the next Tank School courses being conducted over the next
90 days or take the NC DEQ on-line course for retraining. Retraining as a Primary Operator must be completed and
a Primary Operator training certificate achieved within 90 days of receipt of this notice.

Corrective actions must be completed and reported to the inspector at the address provided within 30 days of receipt
of this notice, unless otherwise noted in one of the corrective actions listed above. Assessment of civil penalties may
be recommended for violations described in this NOV, as well as, operating permit revocation/denial unless the
violations are corrected. If Pilot Travel Centers, LLC believes that the inspection findings are in error, or if Pilot
Travel Centers, LLC has any questions pertaining to this NOV and/or corrective actions please have it contact me at
[phone] [e-mail].
Sincerely,
Jack Stutts, Environmental Specialist
Division of Waste Management, NC DEQ
Enclosures
cc: Steve Booe w/ Enclosures (electronic)
Files (electronic)

NORTH CAROLINA �
Departmeni of Environmental Quality
Printed: 6/5/2019 12:22 PM
Inspection Result: Failed
Partial Inspection: No
Inspection Date: 6/5/2019
Arrive and Depart Times: 9:55 AM-11:10 AM
North Carolina
Department of Environmental Quality
Underground Storage Tank
UST-10B
Facili ID:
00-0-0000011084
Inspector
Jack Stuffs
Facili Name
PILOT TRAVEL CENTERS 056
Insp.Type
Compliance
Facility Address
2825 LANE STREET
KANNAPOLIS, NC 28081
Cabarrus County
Located facili USTs onsite
Reasons
Routine Compliance
Location
35.497886-80.560618
Permit Exp.
3/31/2020
Facili Phone
704 938-6800
CONTACTS
Contact Type
Contact Information
Manager
JAMES T ASBURY, 3712 CRABTREE RD WAYNESVILLE, NC 28786, Phone: [phone]
since 4/23/2008
Owner
PILOT TRAVEL CENTERS, LLC , 5508 LONAS DRIVE KNOXVILLE, TN 37909-3221, Phone: [phone]
since 12/18/2001
Regulatory Operator
PILOT TRAVEL CENTERS, LLC , 5508 LONAS DRIVE KNOXVILLE, TN 37909-3221, Phone: [phone]
since 12/18/2001
OWNERSHIP CHANGE
New Owner Chan a Date Basis Transfer of Ownership Form UST-15 Submitted
EMERGENCY RESPONSE
Emergency response placard with emergency response operator contact information is posted in the dispensing areas if the NIA
dispensers are left on without an attendant present?
OTHER PARTICIPANTS
Name Organization
KEITH CARLTON PILOT
INSPECTOR COMMENTS
Type I Date Comment
ADDITIONAL INSPECTOR COMMENTS
Page 1 of 21 6/5/2019 12:23 PM

UST-10B
I
Facility [D: OD-O-OOOODI IDB4
I
TANKS AND PIPING INFORMATION
Tanks
Tank #1(All - DIESEL)
Tank #2(D DIESEL 1)
Tank #3(B2 -
PREMIUM)
Tank #4(E DIESEL 2)
Tank #5(C3 -
REGULAR
Tank ID
Al - DIESEL
D DIESEL 1
B2 - PREMIUM
E DIESEL 2
C3 - REGULAR
TIMS Tank ID
A
D
B i
E I
C
Is tank re istered?
Yes
Yes
Yes
Yes I
Yes
Date tank installed
6/30/1994
6/30/1994
6/30/1994
6/30/1994
6/30/1994
Capacity of Tank in
Gallons
4000
20000
'
10000
20000
15000
Diameter Inches
I
I
Tank / Product use
Motor Fuel
Motor Fuel
Motor Fuel I
Motor Fuel
Motor Fuel
Product stored in Tank
Diesel
Diesel
Gasoline Gas Mix I
Diesel I
Gasoline Gas Mix
Product Detail
Premium I
I
Regular
If hazardous substance,
CAS# or description
(
#
If other, description
I
Tank status
Current
Current
Current k
Current I
Current
Tank closure report
submitted
+
i
I
Date tank last operated
I
i
Inches of product in
Tank
I
+
I
Compartment tank
No
No
No
No I
No
Base compartment
[
I
Other compartment(s)
i
Manifolded tank
No
No
No ;
No I
No
Master manifold tank
I
Manifolded with tanks
I
New Tank System
installed in accordance
with NC or MI
Yes
Yes
Yes
I I
Yes I
{
Yes
Tank Construction
Material (DW required
after 11/1/07
Single Wall Steel
Single Wall Steel
Single Wall Steel
Single Wall Steel
I
Single Wall Steel
If other, description
I
Tank
Manufacturer/Model
General industries:
STIP3 SW
General Industries:
STIP3 S
General Industries:
STIP3 SW
General Industries:
STIP3 S
General Industries:
STIP3 S
If other, describe
I
-Tank material verified by
UST-7A/B
UST-7A/B
UST-7A/B
UST-7A/B
UST-7A/B
Date Pipe Installed
6/30/1994
6/30/1994
6/30/1994
6/30/1994
6/30/1994
Page 2 of 21 6/5/2019 12:23 PM

UST-10B
Facility ID: 00-0-0000011084
Tanks
Tank #1(Al - DIESEL)
Tank #2(D DIESEL 1)
Tank #3(B2 -
Tank 94(E DIESEL 2)
Tank #5(C3 -
PREMIUM)
REGULAR
Was UST Piping
No
No
No
No
No
Installed on or after
11 /1 /2007?
Piping Construction
Single Wall FRP
Single Wall FRP
Single Wall Flex
Single Wall FRP
Single Wall Flex
Material (DW required
after 11/1/07
If other, description
Pipe
Unknown
Unknown.
Unknown
Unknown
Unknown
Manufacturer/Model
If other, describe
Pipe material verified by
UST-7A/B
UST-7A/B
UST-7A/B
UST-7A/B
UST-7A/B
If E-blend > 10% or
NIA
NIA
N/A
NIA
NIA
Biodiesel Blend > 20%;
Was UST-20 completed
and approved?
CORROSION PROTECTION
Tank Corrosion
Tank #1(Al - DIESEL)
Tank #2(D DIESEL 1)
Tank #3(B2 -
Tank #4(E DIESEL 2)
Tank #5(C3 -
Protection
PREMIUM)
REGULAR
DWM notified of current
Yes
Yes
Yes
Yes
Yes
CP method
Integrity assessment
No
No
No
No
No
erformed after 3/1106
CP Method 1
Sacrificial Anodes
Sacrificial Anodes
Sacrificial Anodes
Sacrificial Anodes
Sacrificial Anodes
if other, Description
CP Installation Date
6/30/1994
6/30/1994
6/30/1994
6/30/1994
6/30/1994
CP Method 2
if other, Description
CP Installation Date
Flex Connector, Piping
Ball Valve, Elbow, Flex
Ball Valve, Elbow, Flex
Ball Valve, Elbow, Flex
Bali Valve, Elbow, Flex
Ball Valve, Elbow, Flex
Extensions, and/or other
Connector
Connector
Connector
Connector
Connector
metal fittings Present
Flex connector isolated
Yes
Yes
Yes
Yes
Yes
from around
Source of verification of
Visual
Visual
Visual
Visual
Visual
CP for Flex Connectors,
piping extensions and/or
other metal fittings
if other, Description
Submersible pump
Yes
Yes
Yes
Yes
Yes
STP is isolated from
Page 3 of 21 6/5/2019 12:23 PM

UST-10B
Facility ID: 00-0-0000011084
Tank Corrosion
Tank #1(A1 - DIESEL)
Tank #2(D DIESEL 1)
Tank #3(B2 -
Tank #4(E DIESEL 2)
Tank #5(C3 -
Protection
PREMIUM)
REGULAR
round
Piping extensions and/or
Yes
Yes
Yes
Yes
Yes
other metal fittings are
F
isolated from ground
,
Flex connector, STP
N/A
N/A
N/A
N/A
N/A
and/or other metal
fittings protected from
corrosion
Corrosion protection
L
method
,
Flex connector, Piping
extensions, and/or other
I
metal fittings CP
Installation Date
Dielectric Coating
N/A
NIA
N/A
N/A
NIA
Installed (If tank installed
after 12/22/88
Pipe Corrosion Protection
Tank #1 Al - DIESEL
Tank #2 D DIESEL 1
Tank #3 B2 - PREMIUM
Tank #4 E DIESEL 2
Tank #5 C3 - REGULAR
DWM notified of current CP
method
Yes
Yes
Yes
Yes
Yes
CP method
FRP Piping
FRP Piping
FRP Pi2ing
FRP Piping
FRP Piping
if other, Description
CP Installation Date
6/30/1994
6/30/1994
6/30/1994
6/30/1994
6/30/1994
Dielectric Coating Installed
(If piping installed after
12/22/88
N/A
N/A
NIA
N/A
N/A
Dispenser Corrosion
Dispenser #1(1/2)
Dispenser #2(314)
Dispenser #3(5/6)
Dispenser #4(7/8)
Dispenser #5(9/10)
Dispenser #6(11/12)
Protection
Flex Connector,
Other Metal, Flex
Other Metal, Flex
Other Metal, Flex
Other Metal, Flex
Other Metal, Flex
Other Metal, Flex
Piping Extensions,
Connector, Elbow
Connector, Elbow
Connector, Elbow
Connector, Elbow
Connector, Elbow
Connector, Elbow
and/or other metal
fittings Present
Flex connector
Yes
Yes
Yes
Yes
Yes
Yes
isolated from ground
Source of verification
Visual
Visual
Visual
Visual
Visual
Visual
of CP for Flex
Connectors, piping
extensions and/or
other metal fittings
Page 4 of 21 6/5/2019 12:23 PM

UST-10B
Facility ID: 00-0-00000I 1084
Dispenser Corrosion
Dispenser #1(1/2)
Dispenser #2(3/4)
Dispenser #3(5/6)
Dispenser #4(7/8)
Dispenser #5(9/10)
Dispenser #6(11 /12)
Protection
if other, Description
Piping extensions
Yes
Yes
Yes
Yes
Yes
Yes
and/or other metal
fittings are isolated
from ground
Flex Connectors,
N/A
N/A
N/A
N/A
N/A
N/A
Piping extensions
and/or other metal
fittings protected
from corrosion
Corrosion protection
Isolated
Isolated
Isolated
Isolated
Isolated
Isolated
method
Flex connector,
Piping extensions,
and/or other metal
fittings CP
Installation Date
Source of
Visual
Visual
Visual
Visual
Visual
Visual
Information for
verification of
corrosion protection
for Riser pipe and
other metal piping
if other, Description
Dispenser Corrosion
Dispenser #7(13) Dispenser #8(D14)
Dispenser #9(D14-
Dispenser #10(D15)
Dispenser #11(D15-
Dispenser #12(D16)
Protection
S)
S
Flex Connector,
Other Metal, Flex = Other Metal, Flex
Other Metal, Flex
Other Metal, Flex
Other Metal, Flex
Other Metal, Flex
Piping Extensions,
Connector, Elbow Connector, Elbow
Connector, Elbow
Connector, Elbow
Connector, Elbow
Connector, Elbow
and/or other metal
fittings Present
Flex connector
Yes
Yes
Yes
Yes
Yes
Yes
isolated from ground
Source of verification
Visual
Visual
Visual
Visual
Visual
Visual
of CP for Flex
Connectors, piping
extensions and/or
other metal fittings
if other, Description
I
Piping extensions
Yes
Yes
Yes
Yes
Yes
Yes
and/or other metal
I
Page 5 of 21 6/5/2019 12:23 PM

UST-10B
Facility ID: 00-0-0000011084
Dispenser Corrosion
Dispenser #7(13)
Dispenser #8(D14)
Disp=user #9(D14-
Dispenser #10(D15)
Dispenser #11(D15-
Dispenser #12(D16)
Protection
S)
S
fittings are isolated
from ground
Flex Connectors,
NIA
NIA
N/A
NIA
NIA
NIA
Piping extensions
and/or other metal
fittings protected
from corrosion
Corrosion protection
Isolated
Isolated
Isolated
Isolated
Isolated
Isolated
method
Flex connector,
Piping extensions,
and/or other metal
fittings CP
Installation Date
Source of
Visual
Visual
Visual
Visual
Visual
Vlsual
Information for
verification of
corrosion protection
for Riser pipe and
other metal piping
if other, Description
Dispenser Corrosion
Dispenser#13(D16-
Dispenser#14(D17)
Dispenser #15(D17-
Dispenser #16(D18)
Dispenser #17(D18-
Dispenser #18(D19)
Protection
11
S)
S
Flex Connector,
Other Metal, Flex
Other Metal, Flex
Othe- Metal, Flex
Other Metal, Flex
Other Metal, Flex
Other Metal, Flex
Piping Extensions,
Connector, Elbow
Connector, Elbow
Conrector, Elbow
Connector, Elbow
Connector, Elbow
Connector, Elbow
and/or other metal
fittings Present
Flex connector
Yes
Yes
Yes
Yes
Yes
Yes
isolated from ground
Source of verification
Visual
Visual
Visual
Visual
Visual
Visual
of CP for Flex
Connectors, piping
extensions and/or
other metal fittings
if other, Description
Piping extensions
Yes
Yes
Yes
Yes
Yes
Yes
and/or other metal
fittings are isolated
from ground
Flex Connectors
NIA
NIA
NIA
NIA
NIA
N/A
Page 6 of 21 6/5/2019 12:23 PM

UST-10B
Facility ID: 00-04000011084
Dispenser Corrosion
Dispenser #13(D16-
Dispenser #14(D17)
Dispenser #15(D17-
Dispenser #16(D18)
Dispenser #17(D18-
Dispenser #18(D19)
Protection
S)
S
S
Piping extensions
and/or other metal
fittings protected
from corrosion
Corrosion protection
Isolated
Isolated
Isolated
Isolated
Isolated
Isolated
method
Flex connector,
Piping extensions,
and/or other metal
fittings CP
Installation Date
Source of
Visual
Visual
Visual
Visual
Visual
Visual
Information for
verification of
corrosion protection
for Riser pipe and
other metal piping
if other Descri tion
Dispenser Corrosion
I Dispenser #19(D19-
Dispenser #20(D20)
Dispenser #21(D20-
Protection
S
S
Flex Connector,
Other Metal, Flex
Other Metal, Flex
Other Metal, Flex
Piping Extensions,
Connector, Elbow
Connector, Elbow
Connector, Elbow
and/or other metal
fittincis Present
Flex connector
Yes
Yes
Yes
isolated from ground
Source of verification
Visual
Visual
Visual
of CP for Flex
Connectors, piping
extensions anti/or
other metal fittings
if other, Description
Piping extensions
Yes
Yes
Yes
and/or other metal
fittings are isolated
from around
Flex Connectors,
NIA
N/A
N/A
Piping extensions
and/or other metal
fittings protected
Page 7 of 21 6/5/2019 12.23 PM

UST-'10B
Facility ID: OD-0-0000011084
Dispenser Corrosion
Dispenser #19(D19-
Dispenser #20(D20)
Dispenser #21(D20-
,
Protection
S
S
from corrosion
p
Corrosion protection
Isolated
Isolated
Isolated
method
Flex connector,
Piping extensions,
and/or other metal
fittings CP
Installation Date
Source of
Visual
Visual
Visual
Information for
°
verification of
corrosion protection
for Riser pipe and
other metal piping
if other, Description
,
CP Conclusions
CP Requirements Met? Yes
Issues
CP Tests
Test #1
Applies to Tanks
#1 Al - DIESEL #2 D DIESEL 1 #3 B2 - PREMIUM #4 E DIESEL 2 #5 C3 - REGULAR
Portion of System Tested
Tanks
Date of last Corrosion Protection Test
11/6/2017
CP Test Result
Pass
Was CP Test done in accordance with National Standard?
Yes
CP Tester Name
CHARLES GAVIN
Certificate Number
7733
Certifying Organization
NACE
CP Testing Company Name
CATHODIC PROTECTION SERVICES
CP Testing Company Phone
423 895-1500
As Left Voltage
As Left Current
UST7 form for last CP test submitted to DWM
Yes
SPILL PREVENTION
Has DWM been notified of spill methods? Yes
S ill/Over€ll Details Tank #1 Al -DIESEL) Tank #2 D DIESEL 1 Tank #3 B2 - PREMIUM Tank #4 E DIESEL 2 Tank #5 C3 -REGULAR)
Page 8 of 21 6/5/2019 12:23 PM

UST-10B
Facility ID: 00-0-0000011084
Spill/Overfill Details
Tank #1 Al -DIESEL)
Tank #2 D DIESEL 1
Tank #3 B2 - PREMIUM
Tank #4 E DIESEL 2
Tank #5 C3 - REGULAR
Is a drop tube resent?
Yes
Yes
Yes
Yes
Yes
Type of Stage I vapor
recovery?
Not Required
Not Required
Dual Point
Not Required
Dual Point
Local Fill
Tank #1 Ai - DIESEL
Tank #2 D DIESEL 1
Tank #3 B2 - PREMIUM
Tank #4 E DIESEL 2
Tank #5 C3 -REGULAR)
Does Tank have a Remote
No
No
No
No
No
or Second Fill?
Spill Protection
Catchment Basin
Catchment Basin
Catchment Basin
Catchment Basin
Catchment Basin
Is Spill prevention
Yes
Yes
Yes
Yes
Yes
equipment provided and
verified?
Manufacturer/Model
Unknown
Unknown
Unknown
Unknown
Unknown
If other, describe
Spill bucket is double-
NIA
NIA
NIA
NIA
NIA
walled?
Monitoring T e UST-6B
IS spilt bucket interstice
monitored every 30 days?
if Installed before 11/1/07
Spill bucket is isolated or
N/A
N/A
NIA
N/A
NIA
made of non -corroding
materials? (If installed after
11/1/07
Date spill prevention
6/30/1994
6/30/1994
6/30/1994
6/30/1994
6/30/1994
provided
Last 12 monthly spill
Yes
Yes
Yes
Yes
Yes
bucket checks completed
and all deficiencies
corrected UST-27
O&M walkthrough
Yes
Yes
Yes
Yes
Yes
inspection completed in
accordance with national
standard (e.g. PEI RP 900)
UST-27 ?
Is spill prevention operating
No
No
Yes
Yes
Yes
properly?
If No select all that apply
Water present
Fuel present
If other, describe
3 Year Tightness Test
1/24/2017
1/24/2017
1/24/2017
1/24/2017
1/24/2017
Date UST-6D/23A
Primary Tightness Test
Pass
Pass
Pass
Pass
Pass
Resul UST-6D/23A
Page 9 of 21 6/5/2019 12:23 PM

UST-10B
Facility ID: 00-0-0000011084
Local Fill
Tank #1 Al - DIESEL
Tank #2 D DIESEL 1
Tank #3 B2 - PREMIUM
Tank #4 E DIESEL 2
Tank #5 C3 -REGULAR)
Secondary Tightness Test
Result UST-6D123A
I
Tightness Testing done in
Yes
Yes
Yes
Yes
Yes
accordance with a
standard?
'
OVERFILL PREVENTION
Has DWM been notified of overtiii methods? Yes
Overfill Control
Tank #1 Al - DIESEL
Tank #2 D DIESEL 1
Tank #3 B2 - PREMIUM
Tank #4 E DIESEL 2
Tank #5 C3 - REGULAR
Is overfill prevention
equipment provided and
verified?
Yes
Yes
Yes
Yes
Yes
Date overfill control
rovided
6/30/1994
6/30/1994
I
6/30/1994
6/30/1994
6/30/1994
Type of overfill equipment
Auto Shutoff Device
Ball Float Valve
Ball Float Valve
Sall Float Valve
Ball Float Valve
Source of information for
overfill control verification
UST-22A
UST-22A
UST-22A I
UST-22A
UST-22A
If other, describe
Is overfill control operating
properly?
Yes
Yes
Yes
Yes
Yes
If No, select all that apply
If other, describe
Overfill check date (UST-
22A
6/5/2019
6/5/2019
6/5/2019
6/5/2019
6/5/2019
Overfill check result (UST-
22A
Fail
Fail
Fail
Fail
Fail
Ca aci of Tank in Gallons
4000
20000
1 0000
20000
15000
Diameter Inches
Dispenser Sums
Dispenser #1 1/2
Dispenser #2 314
Dispenser #3 5/6
Dispenser #4 718
Dispenser #5 9/10
Dispenser #6 11112
Are containment
sums resent?
Yes
Yes
F
Yes
Yes
Yes
Yes
Installation Date
6/3011994
6130/1994
6/30/1994
6/30/1994
6/30/1994
6/30/1994
Sump Manufacturer
OPW: Flexworks
Disp Sump___Disp
OPW: Flexworks
Sump
OPW: Flexworks
Disp Surne
OPW: Flexworks
DiS12 Sump
OPW: Flexworks
Disp Sump
OPW: Flexworks
DiSP Sum
If Other (Specify)
Sump Construction
Type
Single Walled
Single Walled
Single Walled
Single Walled
Single Walled
Single Walled
Sump Construction
Material
Plastic
Plastic
Plastic
Plastic
Plastic
Plastic
Page 10 of 21 6/5/2019 12:23 PM

UST-10B
Facility ID: 00-0-0000011084
Dispenser Sums
Dispenser #1 1/2
Dispenser #2 3/4
Dispenser #3 5/6
Dispenser #4 7/8
Dispenser #5 9/10
Dispenser #6 11/12
If Other (Specify)
Are containment
No
No
No
No
No
No
sumps monitored?
Is monitoring
No
No
No
No
No
No
required per 2N
.0900?
Piping components
No
No
No
No
No
No
and/or STP were
installed/replaced on
or after 11 /1 /07?
Are spills or small
No
No
No
No
No
No
weeps evident in
sumps?
Are single wall
piping components
located in
containment sump?
(If installed after
11 /1 /07
UDC Visual
11/16/2018
11/16/2018
11/16/2018
11/16/2018
11/16/2018
11/16/2018
Inspection
Date(annually)(UST-
22C
UDC Visual
Pass
Pass
Pass
Pass
Pass
Pass
Inspection
Results UST-22C
Annual containment
Yes
Yes
Yes
Yes
Yes
Yes
sump check
completed in
accordance with
national standard
(e.g. PEI RP 900 ?
Dispenser Sumps
Dispenser #7(13)
Dispenser #8(D14)
Dispenser #9(D14-
S)
Dispenser #10(D15)
Dispenser #11(D15-
5
Dispenser #12(D16)
Are containment
sums resent?
Yes
Yes
Yes
Yes
Yes
Yes
Installation Date
6/30/1994
6/30/1994
6/30/1994
6/30/1994
6/30/1994
6/30/1994
Sump Manufacturer
Environ: Disp Sump
Unknown
Unknown
Unknown
Unknown
Unknown
If Other (Specify)
Sump Construction
Type
Single Walled
Single Walled
Single Walled
Single Walled
Single Wailed
Single Walled
Page 11 of 21 6/5/2019 12:23 PM

UST-10B
Facility ID: 00-0-0000011084
Dispenser Sumps
Dispenser #7(13)
Dispenser #8(D14)
Dispenser #9(D14-
Dispenser #10(D 15)
Dispenser #11(D15-
Dispenser #12(D16)
S)
S
Sump Construction
Plastic
Plastic
Plastic
Plastic
Plastic
Plastic
Material
If Other (Specify)
Are containment
No
No
No
No
No
No
sumps monitored?
Is monitoring
No
No
No
No
No
No
required per 2N
.0900?
Piping components
No
No
No
No
No
No
and/or STP were
installed/replaced on
or after 1111 /07?
Are spills or small
No
No
No
No
No
No
weeps evident in
sum s?
Are single wall
piping components
located in
containment sump?
(If installed after
11 /1 /07
UDC Visual
11/16/2018
11/16/2018
11/16/2018
11/16/2018
11/16/2018
11/16/2018
Inspection
Date(annually)(UST-
22C
UDC Visual
Pass
Pass
Pass
Pass
Pass
Pass
Inspection
Results UST-22C
Annual containment
Yes
Yes
Yes
Yes
Yes
Yes
sump check
completed in
'
accordance with
national standard
(e.g. PEI RP 900
Dispenser Sumps
Dispenser #13(D16-
S)
Dispenser #14(D17)
Dispenser #15(D17-
S
Dispenser #16(D 18)
Dispenser #17(D18-
S
Dispenser #18(D19)
Are containment
sums resent?
Yes
Yes
Yes
Yes
Yes
Yes
Installation Date
6/30/1994
6/3011994
6/3011994
6/30/1994
6/30/1994
6/30/1994
Sump Manufacturer
I Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Page 12 of 21 6/5/2019 12:23 PM

UST-10B
Facility ID: 00-0-0000OI 1084
Dispenser Sumps
Dispenser #13(D16-
Dispenser #14(D17)
Dispenser #15(D17-
Dispenser #16(D18)
Dispenser #17(D18-
Dispenser #18(D19)
If Other(Specify)I
Sump Construction
Single Walled
Single Walled
Single Walled
Single Walled
Single Walled
Single Walled
Type
'
i
Sump Construction
Plastic
Plastic
Plastic
Plastic
Plastic
Plastic
Material
If Other (Specify)
Are containment
No
No
No
No
No
No
sumps monitored?
Is monitoring
No
No
No
No
No
No
required per 2N
.0900?
Piping components
No
No
No
No
No
No
and/or STP were
installed/replaced on
or after 11/1/07?
Are spills or small
No
No
No
No
No
No
weeps evident in
sumps?
Are single wall
piping components
located in
containment sump?
(If installed after
11 /1 /07
UDC Visual
11/16/2018
11/16/2018
11/16/2018
11/16/2018
11/16/2018
11/16/2018
Inspection
Date(annually)(UST-
22C
UDC Visual
Pass
Pass
Pass
Pass
Pass
Pass
Inspection
Result UST-22C
Annual containment
Yes
Yes
Yes
Yes
Yes
Yes
sump check
completed in
accordance with
national standard
e.. PEI RP 900 ?
Dispenser Sumps
Dispenser #19(D19-
S)
Dispenser #20(D20)
Dispenser #21(D20-
is)
Are containment
Yes
Yes I Yes
Page 13 of 21 6/5/2019 12:23 PM

UST-1 QB
I
Facility ID: 00-0-0000011 D64
Dispenser Sumps
Dispenser#19(D19-
Dispenser#20(D20)
Dispenser #21(D20-
S)___S
sums resent?
Installation Date
6/30/1994
6/30/1994
6/30A994
Sump Manufacturer
Unknown
Unknown
Unknown
If Other (Specify)
Sump Construction
Single Walled
Single Walled
Single Walled
Type
Sump Construction
Plastic
Plastic
Plastic
Material
If Other (Specify)
Are containment
No
No
No
sumes monitored?
Is monitoring
No
No
No
required per 2N
.0900?
Piping components
No
No
No
and/or STP were
I
installed/replaced on
or after 11 /1 /07?
"
Are spills or small
No
Yes
No
weeps evident in
sumps?
Are single wall
piping components
located in
containment sump?
(If installed after
11 /1 /07
UDC Visual
11/16/2018
11/16/2018
11/16/2018
Inspection
Date(annually)(UST-
22C
UDC Visual
Pass
Pass
Pass
Inspection
I
Results UST-22C
Annual containment
Yes
Yes
Yes
sump check
completed in
accordance with
national standard
(e.g. PEI RP 900 ?
Page 14 of 21 6/5/2019 12:23 PM

UST-10B
Facility ID: 00-0-0000011084
Other Sumps
Sump#1(D TRANS)
Sump#2(D1 PLOW)
Sump#3(D1 STP)
Sump#4(D2 PLOW)
Sump#5(D2 STP)
Sump#6(PREM
STP
Are containment
Yes
Yes
Yes
Yes
Yes
Yes
sums resent?
Installation Date
6/30/1994
6/30/1994
6/30/1994
6/30/1994
6/30/1994
6/30/1994
Sump Manufacturer
Environ: Tank Sump
Environ: Tank Sump
Environ: Tank Sump
Environ: Tank Sump
Environ: Tank Sump
Total Containment:
Tank Sum
If Other (Specify)
Sump Construction
Single Walled
Single Walled
Single Walled
Single Walled
Single Walled
Single Walled
Type
Sump Construction
Plastic
Plastic
Plastic
Plastic
Plastic
Plastic
Material
If Other (Specify)
Are containment
No
No
No
No
No
No
sumps monitored?
Is monitoring
No
No
No
No
No
No
required per 2N
.0900?
Piping components
No
No
No
No
No
No
and/or STP were
installed/replaced on
or after 11/1/07?
Are spills or small
No
No
No
No
No
No
weeps evident in
sumps?
Are single wall
piping components
located in
containment sump?
(If installed after
11/1/07
Sump Visual
11/16/2018
11/16/2018
11/16/2019
11/16/2018
11/16/2018
11/16/2018
Inspection
Date(annually)
UST-22C
Sump Visual
Pass
Pass
Pass
Pass
Pass
Pass
Inspection
Result UST-22C
Annual containment
Yes
Yes
Yes
Yes
Yes
Yes
sump check
completed in
accordance with
national standard
Page 15 of 21 6/5/2019 12:23 PM

UST-10B
Facility ID: 00-0-0000011084
Other Sumps
Sump#1(D TRANS)
Sump#2(D1 FLOW)
Sump#3(D1 STP)
Sump#4(D2 FLOW)
Sump#5(D2 STP)
Sump#6(PREM
STP
(e.g. PEI RP 900 ?
Other Sums
Sum 7 REG STP
Sum TRANS 1
Sum 9 TRANS 2
Are containment
Yes
Yes
Yes
sums resent?
i
Installation Date
6/30/1994
6/30/1994
6/30,1994
Sump Manufacturer
Total Containment:
Environ: Tank Sump
Environ: Tank Sump
Tank Sum
If Other (Specify)
Sump Construction
Single Walled
Single Walled
Single Walled
Type
Sump Construction
Plastic
Plastic
Plastic
�
Material
If Other (Specify)
Are containment
No
No
No
sumps monitored?
Is monitoring
No
No
No
E
required per 2N
.0900?
Piping components
No
No
No
,
and/or STP were
installed/replaced on
or after 11 /1 /07?
Are spills or small
No
No
No
weeps evident in
1
sumps?
Are single wall
piping components
located in
containment sump?
(If installed after
11 /1/07
Sump Visual
11/16/2018
11/16/2018
11/16/2018
Inspection
Date(annually)
UST-22C
Sump Visual
Pass
Pass
Pass
Inspection
Results UST-22C
Annual containment
Yes
Yes
Yes
sump check
Page 16 of 21 6/5/2019 12:23 PM

UST-10B
Facility ID: 00-0-0000011084
Other Sums
Sum 7 REG STP
Sum TRANS 1
Sum TRANS 2
completed in
accordance with
national standard
(e.g. PEI RP 900 ?
SITING AND SECONDARY CONTAINMENT
Siting And ;. --�' . ...�zr
-Sec.Containment-General:.;
;Tank #1(A1 - DIESEL) ..
Tank #2(D DIESEL 1)
Tank #3(132 - PREMIUM)
Tank #4(E DIESEL 2)
Tank #5(C3 - REGULAR)
UST system upgraded with
NIA
NIA
NIA
NIA
NIA
corrosion protection, spill
and overfill before 1/1/91?
UST system and/or piping
No
No
No
No
No
are located within siting
and secondary
containment areas?
LEAK DETECTION
General .
Tank #1(A1 - DIESEL)
"'
Tank #2(D DIESEL 1)
Tank #3(B2 -
PREMIUM)
Tank #4(E DIESEL 2)
Tank #5(C3 -
REGULAR
DWM notified of leak
detection method?
Yes
Yes
Yes
Yes
Yes
Piping Type
Piping type
European Suction
Pressurized System
Pressurized System
Pressurized System__
Pressurized System
Suction check a
Dispenser
Type LLD present.
Not Required
MLLD
MLLD
MLLD
MLLD
Tank Release Detection
Primary leak detection
method
Statistical Inventory
Reconciliation SIR
Statistical Inventory
Reconciliation SIR
Statistical Inventory
Reconciliation SIR
Statistical Inventory
Reconciliation SIR
Statistical Inventory
Reconciliation SIR
if other, s eci
Primary LD install date
6/30/1994
6/30/1994
6/30/1994
6/30/1994
6/30/1994
Secondary leak
detection method
if other, s ed
Piping Release
Detection
Primary leak detection
method
Line Tightness Testing
(LTT)
Line Tightness Testing
(LTT)
Line Tightness Testing
(LTT)
Line Tightness Testing
(LTT)
Line Tightness Testing
(LTT
if other, specify
Primary LD install date
6/30/1994
6/30/1994
6/30/1994
1 6/30/1994
6/30/1994
Page 17 of 21 6/5/2019 12:23 PM

UST-10B
Facility ID: 00-0-0000011054
General
Tank #1 (Ai - DIESEL)
Tank #2(D DIESEL 1)
Tank #3(B2 -
Tank #4(E DIESEL 2)
Tank #5(C3 -
PREMIUM)
REGULAR
Secondary leak
detection method
if other, specify
Equipment Checks
Last 12 monthly RD
Yes
Yes
Yes
Yes
Yes
equipment checks
completed and all
deficiencies corrected
UST-27 ?
if no, select all that
apply
Annual handheld RD
Yes
Yes
Yes
Yes
Yes
equipment check
completed and all
deficiencies corrected?
if no, select all that
apply
annual handheld RD
11/162018
11/162018
11/162018
11/162018
11/162018
equipment check date
RD Equipment checks
Yes
Yes
Yes
Yes
Yes
completed in
accordance with national
standard (e.g. PEI RP
900) (UST-27 ?
PIPING LEAK DETECTION
Pressurized Piping
Tank #2(D DIESEL 1
Tank #3(B2 - PREMIUM)____Tank
#4(E DIESEL 2
Tank #5(C3 - REGULAR
Last MLLD/ELLD Test Date
11/16/2018
11/16/2018
11/16/2018
11/16/2018
MLLD/ELLD Test Result
Pass
Pass
Pass
Pass
Last LTT Test Date
11/16/2018
11/16/2018
11/16/2018
11/162018
LTT Test Result
Pass
Pass
Pass
Pass
Does test result indicatesus ected release?
No
No
No
No
Number of MLLD/ELLD Types
1
1
1
1
MLLD/ELLD Equipment
Tank #2(D DIESEL 1) LLD #1
Tank #3(B2 -PREMIUM) LLD
#1
Tank #4(E DIESEL 2) LLD #1
Tank #5(C3 - REGULAR) LLD
#1
MLLD/ELLD
Manufacturer/Model
FE Petro: STP-MLD-D
Red Jacket: FX1V
FE Petro: STP-MLD-D
Red Jacket: FX1V
If other, describe
MLLD/ELLD Thirdfarty
Yes
Yes
Yes
Yes
Page 18 of 21 6/5/2019 12:23 PM

UST-10B
Facility ID: 00-0-0000OI1084
MLLD/ELLD Equipment
Tank #2(D DIESEL 1) LLD #1
Tank #3(B2 -PREMIUM) LLD
#1
Tank #4(E DIESEL 2) LLD #1
Tank #5(C3 - REGULAR) LLD
#1
Certified?
European Suction
Tank #1 Al - DIESEL
Requirements for European suction piping verified?
Yes
Source of information for European Suction verification.
UST Equipment Contractor Report
If other, _Wecify
STATISTICAL_ INVENTORY RECONCILIATION
SIR Systems
SIR #1
SIR Manufacturer/Model
Warren Rogers: PetroNet S3 D CITLDS
If other, describe
SIR Third Party Certified?
Yes
SIR Monthly LD
Tank #1 Al -DIESEL)
Tank #2 D DIESEL 1
Tank #3 B2 - PREMIUM
Tank #4 E DIESEL 2
Tank #5 C3 - REGULAR
2019 Jun
Pass
Pass
Pass
Pass
Pass
2019 May
Pass
Pass
Pass
Pass
Pass
2019 Apr
Pass
Pass
Pass
Pass
Pass
2019 Mar
Pass
Pass
Pass
Pass
Pass
2019 Feb
Pass
Pass
Pass
Pass
Pass
2019 Jan
Pass
Pass
Pass
Pass
Pass
2018 Dec
Pass
Pass
Pass
Pass
Pass
2018 Nov
Pass
Pass
Pass
Pass
Pass
2018 Oct
Pass
Pass
Pass
Pass
Pass
Page 19 of 21 6/5/2019 12:23 PM

UST-10B
i
Facility ID: 00-0-000001IC84
SIR Monthly LD
Tank #1 Al - DIESEL
Tank #2 D DIESEL 1
Tank #3 B2 - PREMIUM
Tank #4 E DIESEL 2
Tank #5 C3 - REGULAR
2018 Sep
Pass
Pass
Pass i
Pass
Pass
2018 AugPass
Pass
Pass a
Pass
Pass
2018 Jul
Pass
Pass
Pass +
Pass
Pass
SIR Conclusions
Leak Detection Requirements Met? Yes
Do the results indicate a suspected release?
Issues
Electronic Data Collection
EIDC System #1
EIDC Manufacturer/Model
V-R: TLS-350 CSLD I
If other, describe
I i
Tanks
#1 Al - DIESEL), #2 D DIESEL 1), #3 B2 - PREMIUM), #4 E DIESEL 2), #5 C3 - REGULAR
z1 WA l:1-
Re airs
Any Repair Issues? I No
+ I
Issues
TRANSMRTFRlFUIPL nFLIVFRV INFORMATION 4
DeliveN Information
Tank #1 Al -DIESEL)
#2 D DIESEL 1
Tank #3 B2 - PREMIUM
Tank # E DIESEL 2
Tank #5 C3 - REGULAR
All deliveries made to
ermitted tanks
Yes
tank
s
Yes
i
Yes
Yes
Page 20 of 21 6/5/2019 12:23 PM

UST-10B
Facility ID: 00-0-0000011084
SITE DIAGRAM 1
C:OAS SIDE
D sucrlOri Aff FLEX @CM PUKPS
R 9
iY
Building FACING LANE STREET
TRUCK STOP SIDE
BACK OF BUILDINGS
17
Y
1S 1 I�
k
S
19
II J�J
�U
s
gg
6-.
20
6
21 I
R=
23 2, Ott
s=
1 t
�3
HE
q#
8`
D D
I�
,45 a!w
I i
iAHIFOLD
00-0-0000011084 on 6+ 512019
Page 21 of 21 6/5/2019 12:23 PM

UST-17B UST Suspected Release 7 Day Notice KC
Q�
➢ This form must be used to report to DEQ, within 7 days of discovery, the investigation results for a Suspected Release from any of the following:
a) Failed or inconclusive leak detection or tightness test results. This includes positive test results, such as "Increase", which indicates the level in the
UST system has increased more than 0.2 gph.
b) Unusual operating conditions which can include, but are not limited to, the erratic behavior of dispensing equipment; the unexplained presence of
water in the tank; the presence of fuel in containment sumps or interstitial spaces; or the degradation of any equipment or element of an underground
storage tank system to the point where that equipment or element can not reasonably be expected to perform its intended function.
c) Internal inspection results such as, perforations, corrosion holes, weld failures, or other similar defects that indicate a release could have occurred.
➢ If you have more than four UST systems to report suspected release investigations, then attach additional sheets of the UST-17B form.
➢ Please submit this form along with the supporting documentation to:
NCDEQ/DWM, UST Section
1646 Mail Service Center
Raleigh, North Carolina 27699-1646
OR
Fax to [phone] OR UST.PermitsCaLncdenr.gov
I. UST OWNER II. UST FACILITY
Name: : Name: Facility ID
P, �nZ— 005 c�
Address: Address:
v
City: State: Zip: City: County:
�� c71 4S INr— 2 2tpq �w,r. v.c� 0 1 t S C_0 Jc�v'1 U S
Person Reporting: Title of Pin Reporting: Telephone Number:
1 rL�.s. s icA, v,(74 5—leg. yLl7'r
III. INVESTIGATION RESULTS
Tank Number / Size:
Product Stored:��. '
Reason for Suspected
Release Investigation
(Check all that apply):
You must attach the
supporting documentation
specified in the footnote for
the reason(s) selected.
❑ Data entry error'
❑ Dispensing fuel while
test is being conducted 2
❑ Faulty equipment 3
❑ Incorrect stick or meter
reading '
❑ Incorrect tank chart °
❑ Internal Inspection 5
❑ Meter not calibrated 6
❑ Other (Attach
explanation)'
❑ Tank/Dispenser
containment sump
contains liquid 7
❑ Tilted tank 6
❑ Unknown'
' Conduct a tank and/or line tightness test and attach the results, along with all of the supporting data sheets for the test method, to this form for submittal.
The summary page listing the results by itself is not acceptable. If the tightness test results are fail, then you must repair or replace your UST system and
conduct a site check in accordance with 15A NCAC 2N .0603.
2 Provide sales receipts or other comparable documentation that shows fuel was being dispensed from the UST during the test.
3 Provide invoices (with a description of the work completed) or other documentation that shows the equipment has been repaired.
4 Correct your leak detection results using the correct tank chart and submit copies with this form.
5 Repair the UST in accordance with the manufacturer's instructions or a national standard (e.g., PEI API 1631) and conduct a site check in accordance with
15A NCAC 2N .0603. If the UST is not repaired, then it must be permanently closed in accordance with the latest version of the UST Sections Guidelines
for Tank Closure.
❑ Data entry error'
❑ Dispensing fuel while
test is being conducted 2
❑ Faulty equipment 3
❑ Incorrect stick or meter
reading'
❑ Incorrect tank chart °
❑ Internal Inspection 5
❑ Meter not calibrated 6
❑ Other (Attach
explanation)'
KTank/Dispenser
containment sump
contains liquid'
❑ Tilted tank 6
❑ Unknown'
❑ Data entry error'
❑ Dispensing fuel while
test is being conducted 2
❑ Faulty equipment 3
❑ Incorrect stick or meter
reading'
❑ Incorrect tank chart °
❑ Internal Inspection 5
❑ Meter not calibrated 6
❑ Other (Attach
explanation)'
❑ Tank/Dispenser
containment sump
contains liquid 7
❑ Tilted tank 6
❑ Unknown'
❑ Data entry error'
❑ Dispensing fuel while
test is being conducted 2
❑ Faulty equipment 3
❑ Incorrect stick or meter
reading'
❑ Incorrect tank chart °
❑ Internal Inspection 5
❑ Meter not calibrated 6
❑ Other (Attach
explanation)'
❑ Tank/Dispenser
containment sump
contains liquid'
❑ Tilted tank 6
❑ Unknown'
6 Correct your leak detection results using the amount your meter was adjusted following calibration and submit copies of the meter calibration and leak
detection results with this form.
' Conduct a tightness test (e.g., hydrostatic test) of the sump and submit the test result along with this form. If the test results are fail, then you must repair
or replace the containment sump and conduct a site check in accordance with 15A NCAC 2N .0603.
6 Submit documentation from your UST equipment contractor explaining how they determined the UST was tilted. Correct your leak detection results using a
tank chart adjusted for the tilt and submit with this form.
Note: Tank, piping, spill bucket and containment sump replacements must be done in accordance with 15A NCAC 2N .0900
UST-17B Revised 10/2016 http://www.wastenotnc.org/web/wm/

�11
UST-6Fif23B Triennial UST Containment Sump 1 UDC Integrity Testing E
Full height hydrostatic or vacuum test mow— v
If any periodic test fails, a suspected release report must be submitted on a UST-17A form, UST Suspected Release 24 Hour Notice. The suspected
release must be investigated, in accordance with 15A NCAC 2N .0603, and defective equipment repaired or replaced in accordance with 15A NCAC
2N .0404/.0900. Results of the investigation must be submitted on a UST-17B form, UST Suspected Release 7 Day Notice.
Containment sumps installed on or after 11/1/2007 that are not monitored continuously for releases using vacuum, pressure, or hydrostatic interstitial
monitoring methods and all other containment sumps installed prior to 11/1/2007 that are used for interstitial monitoring shall be tightness tested at
installation and every three (3) years thereafter in accordance with the manufacturer's written guidelines, PEI/RP100 "Recommended Practices for
Installation of Underground Liquid Storage Systems" and/or PEI/RP1200 "Recommended Practices for the Testing and Verification of Spill, Overfill,
Leak Detection and Secondary Containment Equipment at UST Facilities."
If a UDC / containment sump fails a periodic tightness test, the sump must be replaced or repaired by the manufacturer, or the manufacturer's
authorized representative in accordance with the manufacturer's specifications, or in accordance with a code of practice developed by a nationally
recognized association.
UST FACILITY
O Operator Name R
OT 51.4
Facility Street Address F;
Z$2� L-C -t 'Sit —
TESTING CONTRACTOR INFORMATION
Company Name rnone E-mail Address
of law, that the testing data provided on this form documents the UST system equipment was tested in accordance with the
nes and the applicable national industry standaisted in 15A NCAC 2N .0406 and/or 15A NCAC 2N .0900.
ity Name
�, at 5(
I certify, under
manufacturer's
e of person conducting test
person conducting test Test Date
Identify UDC/sump (By
Dispenser No. or Tank Number,ispenser,
❑Dispenser
❑Dispenser
Tank Size, Stored Product, e.g.
❑Tank
❑Tank
❑Tank
#1 10k Regular STP, Disp 112,
#; LISP ZO
#
#:
etc.
Transition sumps should be listed above as "TS-XX" (with XX= sump ID#)
Sump Material
❑ FRP
❑ FRP
❑ FRP
Plastic
❑ Plastic
❑ Plastic
Test Type
Hydrostatic
❑ Hydrostatic
❑ Hydrostatic
❑ Vacuum
❑ Vacuum
1 ❑ Vacuum
Indicate units for all measurements sump?Eland debris removed from i _
TcxYes No
Visual inspection (No cracks,
loose parts or separation of the XPass ❑ Fail
containment sump}
Sump Depth in inches I i s"
Height from sump bottom to top
of highest penetration or sump i
sidewall seam in inches
Wait time between applying
vacuum/water and start of test 3c) tr\1d1
Begin i End Test Time
(minimum test time: 1 hour) IC 1 I 1151
Begin i End values (inches) 16 rr i 6 A
[]Dispenser
❑Tank
❑ FRP
❑ Plastic
❑ Hydrostatic
❑ Vacuum
❑Dispenser
❑Tank
❑ FRP
❑ Plastic
❑ Hydrostatic
❑ Vacuum
❑Dispenser
❑Tank
❑ FRP
❑ Plastic
❑ Hydrostatic
❑ Vacuum
❑ Yes ❑ No I ❑ Yes ❑ No I ❑ Yes ❑ No I ❑ Yes ❑ No I ❑ Yes ❑ No
❑ Pass ❑ Fail I ❑ Pass ❑ Fail 1 ❑ Pass ❑ Fail I ❑ Pass ❑ Fail I ❑ Pass ❑ Fail
Pass/Fail criteria: Must pass visual inspection. Hydrostatic: Water level drop of 1/8 inch or more fails the test; Vacuum: No change in vacuum
Test Result Pass El Fall El Pass Elail ❑Pass ❑Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail
Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests)
Date next Containment Sump/UDC integrity test due (required every 3 years)
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION
1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE [phone] FAX [phone] http://www.wastenotne.ora
2/2019

�=IfIY
SPATC I
E N E R 0 Y O L U T I O N S
h ELUL RIVA INDUSI1i:5 COMPANY
Site Information
Service #9712049 PO #19124880-6040919
PILOT TRUCK STOP # 56 Customer #54770
2825 LANE STREET
KANNAPOLIS,NC 28083
United States
Work Performed by Travis Furr
Arrived on site checked in with mod. Pulled up to fp 20 to run a hydrostatic test on the entry boots.
Opens the bottom door and found liquid in the pan I use the compliance trailer to pump out 10 gallons.
I was able to inspect the entry boots and found one completely open I was able to tighten the boot
back to the piping. I filled a 5 gallons bucket up with water and filled the diesel pan on fp 20 to the top
of the entry boot I took measurements of the liquid test started at 10:51 and at 11:51 the test was done
and check my measurements and it was the same the hydrostatic test pass. I pumped the water that I
put in the pan out.
Time On Site
Time Arrived: 6/14/19, 8:45 AM
Time Departed: 6/14/19, 10:30 AM
Total Time on Site: 1 Hours 45 Minutes
Follow up Required?
No followup required.
Customer Signature
Cq1wAAA---,
Savannah Crainshaw
6/14/19,12:10 PM

Beverly, Trudy
From: Beverly, Trudy
Sent: Wednesday, August 21, 2019 1:43 PM
To: Stutts, Jack L
Subject: RE: Pilot Travel Center #056
Jack,
I appreciate the information for CAB records.
Have a wonderful day,
Trudy
From: Stutts, Jack L
Sent: Wednesday, August 21, 2019 1:29 PM
To: Beverly, Trudy <[e-mail]>
Subject: RE: Pilot Travel Center #056
Trudy,
Dispenser 20 had drops of fuel dropping into the UDC, which contained water above the lowest point of
penetration. Let me know if you need anything else.
Jack
From: Beverly, Trudy
Sent: Wednesday, August 21, 2019 11:28 AM
To: Stutts, Jack L <[e-mail]>
Subject: Pilot Travel Center #056
Jack,
What part(s) of the diesel ust systems at Pilot Travel Center #056 were problems with their last inspection
(Facility Id 00-0-0000011084)? Where is the suspected release?
Thanks,
Trudy
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
North Carolina Department of Environmental Quality
UST Section, Mooresville Regional Office
a�
704.235.2182 (Office)
Trudy.Beverlykncdenn 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: ht_pt s:Hdeg.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: https://deg.nc.gov/about/divisions/waste-management/ust/ast-proeram
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httns://dea.nc. eov/about/divisions/waste-management/waste-manaeement-rules-data/waste-manaeement-ais-mans
File Review Procedures:

https: //deq.nc. gov/about/divisions/waste-managementlust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
https://edocs. deq.nc. Qov/WasteManagement/Search.aspx
Document Submittal & UST File Names for Laserfiche Policies:
https://files.nc. gov/ncdeq/Waste%20Mana,gement/D WM/UST/Corrective%20ActionBlectronic%20Document%20Submittal%20Memo%20Update.pdf
htips:Hfiles.nc. gov/ncdeq/Waste%20Management/DWM/UST/Corrective%20Action/UST%20file%20names%20for%20Laserfiche.docx