MO-5469_19033_CA_UST-3_19980512

05/12/11911 16:20 336-784-4548 PAGE 01
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FOR Return Completed Form To: State USe Only
TANKS The appropriate DEM Regional Office according to the county of the facility's l D. Number
IN location. (SEE REVERSE SIDI* OF O1NNER'$ COPY (PINK) FOR REGIONAL.
NC OFFICE ADDRESS). Date Received
V I,NSTRUCTIONS
Complete and return five (5) working days prior to closure or change -in-service.
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Tank Owner Name: Perdue Parma Ina. Facility Name or Company:Perdue Farms Inc.
Str�...1 �ndfries °"°i':Y7"`".Ems►'�r�7 0-02897
Street Address: - - -- Facility ID # (if available): .5
County: Richmond Street Address or State Road: 500 Armentrout Rr�ad
City:Roeki_n�ham State: NC Zip Code:28379 - County: Cfabarrus City: C.Qncord _ Zip Code:28025
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Tole. No. (Area Cade)' Area Code No-
[phone] Tole. [phone]
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Name: Mr. Jimmy Davis JobTitle: Telephone Number:(-9-10 }997-8601
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t - Contact Local Fire Marshall, Underground Petroleum Storage Tank6". 7. The Site assocamont portion of the tank
2. Plan the entire closure event. 5. Provida a sketch locating piping, closure must be conducted under the
3. Ccnduct Site Soil Assessments. tanks and soil sampling locations. supervision of a Professional Engineer
4. If Removing Tanks or Closing in S. Fill out form GW/UST-2 "Site or Licensed Geologist. After January 1.
Place refer to API Publications investigation deport for 1994, all Closuro site aasesement
2015 "Cleaning Petroleum Permanent Closure" and return reports must be signed and sealed
Storage Tanks" & 1604 "Re- within 30 days following the site by a P.E. or L.G.
moval & Disposal of Used investigation. 8. Keep closure records for 3 years.
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(Contractor) Name: Triad Environmental. 'ConouItenta.Inc.
Address: 182C1 Pope Lane ► Kernersville State: North Carolina Zip GOCte:27284
Contact: C. Me1 Howell Phone:_ [phone]
Primary ConsuttantTriad Environmental. Consultants.. Iftne: [phone]
'•:i}}:":<.:.s:.V:l.;'1`A )<'. ,.$.GMF.DULEP.< O,R> ,LOSURt"ffOR;:'CHANG� IIJ .SERVICRt;' I s}, >,• >ar;:..:�t$',:':>:tr::ry;s s:
PROPOSED CTIVITY
TANK IN TANK CAPACITY LAST CONTENTS CLOSURE CHANGE -IN-SERVICE
Removal Abandonment New Contents stored
In Placa
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Print name and official title Triad Enviorrsmantal Conaiiltants r Inc.
C. Mal :):iowal 'Scheduled Removal Date:5/19q8
Signature: Date Submitted;
It scheduled work date changes, notify your appropriale OEM Regional Office 48 hours prior to originally scheduled date.
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