MO-9501_40937_CA_UST-61_20190909_24-Hour Release and UST Leak Reporting Form

UST-62
24-Hour Notification of Discharge
Form
For Non -UST This form should be completed and submitted to the UST Section's regional office following a known or suspected release of
Releases of petroleum from a source other than an underground storage tank. This form is required to be submitted within 24 hours of
Petroleum in NC discovery of a known or suspected petroleum release
(DWM USE ONLY)
Suspected Contamination? (Y/N) N
Release discovered
Incident # Priority Rank (H,I,L,U)
Confirmed GW Contamination? (Y/N) Y1
(time/date): 09/06/2019
Received (time/date)
Confirmed Soil Contamination ?(Y/N) Y
1212
Received by Region
Samples taken?(Y/N) Y Free product? (Y/N) N
Reported by (circle one): Phone, Fax or Report
If Yes(free product), state greatest thickness: feet
INCIDENT DESCRIPTION
Incident Name: GASC 2321 Bay7 Lift
Address (street number/name): 8415 Old Statesville Road
County:
Mecklenburg
City/Town: Charlotte
Zip Code: 28269
Regional Office (circle one): Asheville, Mooresville, Fayetteville,
Raleigh, Washington, Wilmin
on, Winston-Salem
Latitude (decimal degrees): 35.336289 Longitude (decimal degrees) : 80.826383
Obtained by:
❑ GPS
Describe suspected or confirmed release (nature of release, time/date of release, quantity of release, amount of free
product):
❑ Electronic topographic map
❑ GIS Address matching
® Other
Hydraulic lift removal activities were conducted August 17 through 18, 2019. Initial analytical results (TPH) exceeded screening criteria and
subsequent constituent specific compounds exceeded regulatory standards. The volume of the release is unknown.
Describe initial response/abatement (time/date release stopped, cleanup begun/completed, quantity of product
soil removed, confirmation sampling):
❑ Unknown
Describe location:
Automotive Service Center
An estimated 40 tons of soil was excavated during hydraulic lift removal on 8/17-18/2019. Confirmatory samples were collected.
Describe impacted receptors:
Unknown: None suspected
HOW RELEASE WAS DISCOVERED (Release Code)
(Check one)
❑ Observation of Release at Occurrence ❑ Water Supply Well Contamination
❑ Visual or Olfactory Evidence ❑ Surface Water Contamination
0 Soil Contamination ❑ Other (specify)
❑ Groundwater Contamination
SOURCE OF CONTAMINATION
Source of Release Cause of Release Type of Release Product Type Released
(Check one to indicate primary (Check one to indicate primary (Check one) (Check one to indicate primary petroleum product
source) cause)
type released)
❑ AST (tank) ❑ Spill (Accidental) 0 Petroleum ❑ Gasoline/ Diesel/ ❑ Diesel/Veg. Oil
❑ AST Piping/ Dispenser ❑ Spill (Intentional) ❑ Both Petroleum Kerosene Blend
❑ AST Delivery Problem ❑ Corrosion & Non -Petroleum ❑ Ell — E20
❑ Vegetable Oil 100%
❑ OTR Vehicle Tank ❑ Physical or Mechanical ❑ E21 — E84
❑ Heating Oil
❑ OTR Bulk Transport Tank Damage Location ❑ E85 — E99
❑ Waste Oil
❑ RR Bulk Transport Tank ❑ Equipment Failure (Check one) ❑ Ethanol 100% ❑ Mineral Oil -no
❑ Transformer ❑ AST Overfill
❑
PCBs
Facility
❑ Unknown ❑ AST Installation Problem
❑ Residence
❑ Mineral Oil -PCBs
0 Other Hydraulic Lift 0 Unknown
❑ Highway/Road
0 Other Petroleum
Productshydraulic oil
❑ Other
❑ Railway
Definitions presented on reverse Definitions presented on reverse
❑ Other
Ownership
1. Municipal 2. Military 3. Unknown 4. Private 5. Federal 6. County 7. State
Operation Type
1. Public Service 2. Agricultural 3. Residential 4. Education/Relig. 5. Industrial 6. Commercial 7. Mining
Guidance presented on reverse
UST Form 62 (04/10) 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 Unknown
List of Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
1.
2.
3.
PARTY RESPONSIBLE FOR RELEASE
(if the source of the release is not an AST system or if it is an AST system and there is a responsible party other than the AST system owner/operator)
Name of Person/Company
The Goodyear Tire and Rubber Company
Address
200 Innovation Way
City
Akron
State
OH
Zip Code
44333
Telephone Number
1 330-796-7285
AST SYSTEM OWNER (if the source of the release is an AST system)
AST Owner/Company
Address
City
State
Zip Code
Telephone Number
AST SYSTEM OPERATOR (if the source of the release is an AST system)
UST Operator/Company
Address
City
State
Zip Code
Telephone Number
LANDOWNER AT LOCATION OF INCIDENT
Landowner Dennis Eugene Brantley, Sr. & Camarie Keitt Brantley
g Y Y
Address
925 Spears Creek Ct
City Elgin
State SC
Zip Code 29045
Telephone Number
Draw Sketch of Area or Provide Map (showing incidentslte, location of release, two major road intersections, potential
receptors)
Attach sketch or map to form.
Give Directions to Incident Site Attach directions to form if necessary.
Person Reporting Incident Chris Wiley
Company The Goodyear Tire & Rubber Company
Telephone Number 330-796-7285
Title Project Manager
Address 200 Innovation Way
Date September 9, 2019
UST Form 62 (04/10) Page 2 of 2
Definitions of Sources
AST (Tank): means the tank is used to store product
AST Piping: means the piping and connectors running from the tank to the dispenser or other end -use equipment
AST Dispenser: includes the dispenser and the equipment used to connect the dispenser to the piping
AST Delivery Problem: identifies releases that occurred during product delivery to the tank.
OTR Vehicle Tank: means the tank is used to store product to fuel an over the road vehicle
OTR Bulk Transport Tank: means a tank that is used to transport product in bulk over the road (by truck)
RR :bulk Transport Tank: means a tank that is used to transport product in bulk by train
Transformer: means electrical transformer
Other: serves as the option to use when the release source is known but does not fit into one of the preceding categories
Unknown: identifies releases for which the source has not been determined
Definitions of Causes
Spill (Accidental): use this cause when a spill occurs accidentally(e.g., when the delivery hose is disconnected from a fill pipe)
Spill (Intentional): use this cause when a spill occurs intentionally (e.g., intentional dumping or breakage)
Corrosion: use when a metal tank, piping, or other component has a release due to corrosion
Physical or Mechanical Damage: use for all types of physical or mechanical damage, except corrosion
Equipment failure: use when a release occurs due to equipment failure other than corrosion or physical or mechanical damage
AST 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)
AST Installation Problem: use when the problem is determined to have occurred specifically because the AST system was not installed properly
Other: use this option when the cause is known but does not fit into one of the preceding categories
Unknown: use when the cause has not been determined
Guidance: Ownership and Operator Type
Ownership select the category which describes owner of the AST system, bulk transport tank, or other release source
Operator Type select the category which describes the operation in which owner uses the AST system, bulk transport tank, or other release source

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Beverly, Trudy
From:
Sent:
To:
Beverly, Trudy
Monday, September 16, 2019 6:37 AM
Bowser, Daniel P
Cc: Kyle Sorensen; Chris Wiley-CONT; Matthew Eckmair; Joshua Orris; Taraban, Ron
Subject: RE: [External] UST-62 24 Hour Notification of Discharge - Charlotte, NC
Dan —Thanks for passing along the release form.
Kyle — I address non -regulated ust releases in Mecklenburg County. I've been on leave for the last week. Please
send future communications for this site to my attention.
Thank you,
Trudy
D,1E Q:*
bgwtnne wi fmron w Qum" �
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.Beverlykncdenr. 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: httos://deq.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-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httns://deo.nc. eov/about/divisions/waste-management/waste-management-rules-data/waste-management-L,is-mans
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):
https://edocs.deq.nc. gov/WasteManagement/Search.aspxx
Document Submittal & UST File Names for Laserfiche Policies:
hitps://files.nc.gov/ncdeq/Waste%2OManagement/DWM/tJST/Corrective%2OAction/Electronic%2ODocument%2OSubmittal%2OMemo%2OUpdate.pdf
hns://files.nc. gov/ncdeq/Waste%2OManagement/DWM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx
From: Bowser, Daniel P
Sent: Tuesday, September 10, 2019 10:12 AM
To: Beverly, Trudy <[e-mail]>
Subject: Fwd: [External] UST-62 24 Hour Notification of Discharge - Charlotte, NC
This should be a UST-61
Dan Bowser, PG
NCDEQ
Non-reg UST release.

UST Section
Corrective Action Branch
From: Taraban, Ron <[e-mail]>
Sent: Tuesday, September 10, 2019 9:16:59 AM
To: Bowser, Daniel P <[e-mail]>
Subject: FW: [External] UST-62 24 Hour Notification of Discharge - Charlotte, NC
From: Kyle Sorensen <[e-mail]>
Sent: Monday, September 09, 2019 5:34 PM
To: Taraban, Ron <[e-mail]>
Cc: Chris Wiley-CONT <chris [e-mail]>; Matthew Eckmair <[e-mail]>;
Joshua Orris <[e-mail]>
Subject: [External] UST-62 24 Hour Notification of Discharge - Charlotte, NC
External email. Do not click links or open attachments unless you veri
attachment to [e-mail]
Mr. Taraban,
Please find attached a UST-62 Notification form. Soil contamination was confirmed via soil samples collected
following the removal of a hydraulic lift at an automotive service center located at 8415 Old Statesville Road in
Charlotte, Mecklenburg County, North Carolina. Please feel free to reach out with any additional questions or
concerns.
Best Regards,
Kyle
Kyle Sorensen I Project Manager I USA
Antea®Group
Direct [phone] Mobile [phone] USA Toll Free [phone]
3530 Toringdon Way, STE 106, Charlotte, NC 28277
Skype:nccardsfan
[e-mail] I us.anteagroup.com
v
L�
anteagroup
Member of Inogen® I www.inogenet.com

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