MO-1494_0_CA_UST-3_19931210

(qW/UST-3) Notice of Intent: UST Permanent Closure or Change ­lr�Pe
MR
/XANKS
IN
Retum Completed Form To:
The appropriate DEM Regional Office according to the county of the facility's
location. (SEE REVERSE SIDE OF OWNER'S COPY (PINK) FOR REGION
777
State Use `Only
I. D. Number
NC
OFFICE ADDRESS). 7
Date Received­�'-`­``
INSTRUCTIONS
Complete and return thirty (30) days prior to closure or change -in-service.
I. OWNERSHIP OF TANK(S)
0. LOCATION OF TANK(S)
Tank Owner Name: Larry Bost
Facility Name or Company M&M Cash Grocery
(CoMondw. 1ndwdA Rbic Agw", or 00w Er"
Street Address: 1075 Neisler Rd.
Facility ID # (if available) 0-007442
County. Cabarrus
Street ,Address or S Road: 1195 Concord -Salisbury
Concord NC Zip Code: 28025Oncord
City: State:
CoCdntv: Cabarrus City: Zip Code: 28025
Tele. No. (Area Code): 1-704-786-8792
Tele. No. (Area Code): 1-704-782-0861
111. CONTACT PERSON
Name:_ Laar; y Bost Job Title: Owner Telephone Number:(704 ) 782-0861
IV. TANK REMOVAL, CLOSURE IN PLACE, CHANGE4N-SERVICE
1. Contact Local Fire Marshall. 5. Provide a sketch locating piping, tanks and Soil
2. Plan the entire closure event sampling locations.
3. Conduct Site Soil Assessments. 6. Fill out form GWAJST-2 "Site Investigation Report for
4. If Removing Tanks or Closing in Place refer to API Permanent Closure" and return within 30 days
Publications. 2015 "Cleaning Petroleum Storage following the site investigation.
Tanks" & 1604 "Removal & Disposal of Used, 7. Keep records for 3 years.
Underground Petroleum Storage Tanks".
V. WORK TO BE PERFORMED BY:
(Contractor) Name: Burrage Grading Company
Address: 438 Burrage Road, NE,Concord State: NC Zip Code: 28025
Contact: Richard Burrage Phone: [phone]
V1. TANK(S) SCHEDULED FOR CLOSURE OR CHANGE4NI-SERVICE
TANKID# TANK CAPACITY LAST CONTENTS
PROPOSED
ACTIVITY
CLOSURE
CHANGE -IN-SERVICE
Removal
Abandonment
In Place
New Contents Stored
A 2000 Gasoline Regular Gas
B 550 Gasoline Plus Gas
C 550 Gasr)'linc- Pliis Gas
D -9 S 0 Gasnljnp SUprpMp
VII. OWNER OR OWNER'S AUTHORIZED REPRESENTATIVE
Print name and official Ode
LardBost /,)Owner *Scheduled Removal Date: 1-14-93
Signature: JAAZ Date Submitted: 12-10-93
T schedLA work dale charxjes, notify your appropriate DEM Regional Office 48 hours prior to originally scheduled date.
In
MP
GW/UST-3 Rev.7/29/91 Vffile Copy - Regional Office Yellow Copy - Central Office Pink Copy - omw

)Lf'_. .. ��7ITYI, 4
ykf:ember 10, 1993
North Carolina Department of
Environment, Health, and Natural Resources
Division of Environmental Management
919 North Main Street
Mooresville, North Carolina 28115
Reference: Notification of Change of Service or Removal of
Underground Storage Tanks....... UST-31s Included.
M & M Cash Grocery, Concord, North Carolina
Gentlemen:
I would like to perform the change of service by removal of the
above UST's. I am submitting the attached UST-3 form for 30 day
notification. I would like to perform the removal of the UST's
during the week of January 14, 1993.
Thank you for your attention in this matter.
any questions pertaining to this project, please
contact me at your convenience.
Very respectfully,
M & M Cash Grocery
Larry Bost, Owner
enclosures-, 1 --�
If you should have
do not hesitate to

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