MO-2956_0_CA_UST-61_19900207

Identification Results
Page 1 of 1
Parcel Information
Print Ownership and GIS Summary
Parcel Ownership Summary
Parcel ID#: 12110102 GIS /D#: 12110102
Owner Name: CLEMENTI SOUTH LLC
Mailing Address: PO BOX 471904
CHARLOTTE, NC 28247
Property Characteristics
Legal Desc.
Land Area:
Fire District:
Special District:
Account Type:
Municipality:
L6 B2 M332-285
13775 SF
00-CITY OF
CHARLOTTE
N/A
NC CORP
1-CHARLOTTE
Property Use: MULTI -FAMILY
Deed Reference(s) and Sales Price
17045-189 (4/14/2004) $0.00
16840-88 (3/2/2004) $0.00
13099-849 (12/31 /2001) $0.00
12825-078 (10/30/2001) $0.00
10104-284 (12/10/1998) $0.00
Situs Addresses Tied to This Parcel
0' 822 IDEAL WY
Choose an address from the list above and
click on the links below for more
information
Where to Go Vote I School Districts
Parks Within 3 Miles I Get Directions
Links to More Information
Ift Building Photo(s) IN
FEMA, Zoning, Etc. Adjoining Owners
Tax Values & Building Info. Tax Bill Info.
http://maps2.co.mecklenburg.nc.us/website/realestate/Parceldetails.asp 1/7/2005

Dear Under
ground Storage Tank
Beginning (UST) Owner/pperator;
status of g October 11 2004
the latest infOt7na ground 'North Carolina
storage tank release Session Law 2004-
http;//ust.ehnr.state, on implementation assessment or lip may affect the
nc.us/main. g�+idance clean-up efforts.
One critical as ht1n1. °r updated forms TO get
2004 aspect of Session Law � Please visit
Prohibits the De 2004-124
paid from the Co Department from which be
determines that mmercial or Noncol pn rppal vin effective
reimburse sufficient funds t any task, the October 1,
State Trust Fund °Ost of which is to be
paid, went of the cost of tha that within g�I to a claim for paylUnless n i��epal•hnent
To meet the after the claiin O1
requirements of this law, Is eligible to be`'
l) After October 1 the D(`partme following the sub ' 2004 State TrustFund nt is 1e
mittal of quil•ing;
a Limited Site Assess
''F°va] most be received for
2) After October 1, 2004 Assess�,icnt
Requireinents to , The D RePort (15A NC all work
conta direct responsible Will Department will USe AC 2L .0115 (c))
urinated soil and Parties of a Notice of Site Assessment l ground a release to Regulatory
water on a risk -based basis follo assess
Rep 05A NC and remove or clean up
If you have an AC 2L .0115 (c))• wmg submittal a Y questions, please call the UST Limited
Section at [phone].

North Carolina
A7Department of Environment
NCDENR And Natural Resources
Division of Waste Management, UST Section
1637 Mail Service Center
Raleigh NC 27699-1637
':: •thy .. .
5CT w.1. m_ -
US POSTAGE
FIRST CLASS
MAILED FROM 27607
011AO413001373
(5492)
MR BILL KLEMENTY j{_
2308 CRESCENT AVENUE I I I�yQr} 1 !
CHARLOTTE NC 28207
0 A ❑ INSUFFICIENT ADDRESS
c 0 ATTEMPTED NOT KNOWN ❑ OTHER
❑ NO SUCH NUMBER/ STREETTC S ❑ NOT DELIVERABLE AS ADDRESSED i
UNABLE TO FORWARD ,
It IIII,,, If III to l„IIIn,,,II,II,I,►II,If ,, III, ,It

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POLLUTION INCIDENT/U.S.T. LEAK REPORTING FORM
POTENTIAL SOURCE OWNER -OPERATOR
Potential Source Owner -Operator
Telephone
) 70,
Al-/- y
Company
Sheet 4,c1dress
City /L
County
State
lip Code
Za -t
U.S.T. REGISTERED
SOURCE/U.S.T.
PERMIT TYPE
OWNERSHIP
TYPE
YES
NO
IN USE
1 N/A
�/q
0. N/A
_OPERATION
0. /A
2 YES
(!',�. NO
1. Non -discharge
1. Municipal
1. Public Service
FACILITY ID#
SOURCE PERMITTED
2. Oil terminal
2. Military
2. Agricultrural
FEDERAL U.S.T.
1. Yes
DESIGNATION
2 ;0
3. Landfill
Unknown
3. Residential
PERMIT NUMBER
1. Regulated
4. Mining
fl3.
�4�private
4. Educational/Religious
Non Regulated
SOURCE ON
ERRIS LIST
5. NPDES
5. Federal
5. Industrial
STATE U.S.T.
DESIGNATION
1- Yes
2. No
6. RCRA
6. County
6. Commercial
ERRIS NUMBER
Commercial
7. State
7. Mining
Non -Commercial
REASON FOR INCIDENT
1. Transportation
U.S.T. LEAK PREVENTION MEASURES
Was tank retrofitted with overfill protection?
1. Yes
2. Mechanical failure
Olo
When and by whom?
3. Facility
Was tank retrofitted with interior lining?
Yes
4. Inventory only
( ,lNo
��Ilhen and by whom?
5. Human error
Was tank retrofitted with cathodic protection?
l.Yes
6. Vandalism
0
When by
(:7,�Inknown
and whom?
ACTIONS TAKEN
Investigation, Containment, Cleanup, etc.
7K,121 C>/
1-2
J
Circle Appropriate Responses
Lab Samples Taken By: 1. D.E.M. 2. D.H.S. 3. Responsible Party ( None
Samples Taken Include
1. Groundwater 2. Soli 3. Surface Water

POLLUTION INCIDENT/U.S.T. LEAK REPORTING FORM
POLLUTANTS INVOLVED
MATERIALS INVOLVED AMOUNT STORED OR AMOUNT LOST AMOUNT RECOVERED
TANK CAPACITY
G1n�r�vl�n Gt����o� GWITT-7ow�
IMPACT CAN SURFACE WATERS
Distance to Stream(ft)
WATERS AFFECTED 1. Yes No 3. Potentially
F Name of Stream Stream Class.
Fish Kill 1. Yes 0N0
IMPACT ON DRINKING WATER SUPPLIES
No. of Wells No. of Wells
WELLS AFFECTED 1. Yes. No 3. Potentially Affected Potentially Affected
G
Population Served Estimated Population Served By Aquifer(s) Being Used
By Aff
ected Wells Potentially Affected Wells l . Water Table 2. Confined Bedrock
POTENTIAL SOURCE OF POLLUTION
5
PRIMARY SOURCE OF
POTENTIAL POLLUTION (Select one)
PRIMARY POLLUTANT TYPE
LOCATION
SETTING
(Select one)
1, intentional dump 13. Well
1. Pesticide/herbicide
1. Facility
1. Residential
2. Pit, pond, lagoon 14. Dredge spoil
2. Radioactive waste
2. Railroad
2. Industrial
Leak -underground 15, Nonpoint source
3. Gasoline/diesel
3. Waterway
Urban
01 Heating oil
4. Pipeline
4. Rural
4. Spray irrigation
5. Land application
5. Other petroleum prod.
5, Dumpsite
6. Animal feedlot
.6. Sewage/septage
6. Highway
7. Fertilizers
7 Residence
H
7. Source unknown
8. Septic tank
8. Sludge
8, Other
9. Sewer line
9. Solid waste leachate
Confirmed Violation of:
10. Stockpile
10. Metals
1. 15 NCAC 2L
Yes No
11. Landfill
11. Other Inorganics
2. Article 21A Part I
12. Spill -surface
12. Other organics
Yes No
3. Article 21A Part II
If other sources, list corresponding No's.
Yes No
4. Federal/State U.S.T. rules
If multiple pollutant types, list corresponding No's.
Yes No
if PIRF previously submitted for Nonprimary Sources, list incident No's.

State of North Carolina
Department of Environment,
Health and Natural Resources •
Mooresville Regional Office
James B. Hunt, Jr., Governor Or
HJonathan B. Howes, SecretaryNFZ
DIVISION OF WATER QUALITY
July 18,1996
Dear Underground Storage Tank Owner/Operator:
The General Assembly of North Carolina introduced legislation during the 1995 Short Session to
address the continued solvency of the Leaking Petroleum Underground Storage Tank Cleanup
Funds. The Underground Storage Tank (UST) Senate Bill 1317 (SB 1317) was ratified on June
21, 1996. SB 1317 requires the Department of Environment, Health, and Natural Resources
(Department) to rank all UST -related contamination incidents according to the Department's
revised Site Priority Ranking System which classifies sites as: A,-$ (highest priority), C, D or E
(lower priority). Further, SB 1317 requires the Department to notify the UST owner, operator
and/or other responsible party (RP), as applicable, of the ranking of their site. Please find below
a statement notifying you of the priority ranking the Department has assigned to your site.
Your site has been assigned a priority ranking score oh
MR. BILL KLEMENTY
Site:DILWORTH CROSSING
Incident #: 05492 County: ME
Rank. E?
SB 1317 temporarily suspends the requirement to cleanup a discharge or release from a
petroleum UST for lower priority sites (i.e., those ranked C, D or E). This legislation is effective
July 21, 1996. Therefore, costs for site assessment or corrective actions at C, D or E sites which
are incurred after July 21, 1996, will not be reimbursed from either the Commercial or
919 North Main Sheet, 'r FAX 70,4..�.6040
Mooresville, North Carolina 28115 N%)CAn Equal Opportuntty/Affirmative Action Employer
Voice 704-663-1699 50% recycled/10% post -consumer paper

POLLUTION INCIDENT/U.S.T. LEAK REPORTING FORM v
1. Incident `( ��- Division of Environmental Management
GROUNDWATER SECTION
2. Tabulate only TYPE OF ACTION
1. Emergency Response 3 Complaint Investigation 51 U.S.T. Leak
2. Compliance Investigation . Routine Inventory 6. Other:
A
POTENTIAL HAZARDS: 1. Toxic Chemicals 2. Radioactivity 3. Air Emmissions 4. Explosives •��� 0�0 J
X+ly
INCIDENT DESCRIPTION
t— E&2 z3
r
9n _
Incident Location/Name
Address IF
2 _Lole-a R)Q y
City"" Char'Q11_�
County M bU
Region
Briefly Describe Incident
g
r n E, U ST - 1= T
Date Incident
If L.U.S.T., How Leak 1. Tank Gauging 5. Interstitial Monitoring Other /rnn
Occurred or Leak
Was Detected
Detected
2. Vapor Monitoring 6. Tank Removal R�bn
3. GW Monitoring 7. Tightness Test
4. Contractor who tightness tested, removed tank, or Installed leak
detection system.
IC
PERSON REPORTING INCIDENT
Name
/�so7 o/22/77'
Company/Agency
REPORTED BY: 1. Tank owner/opefator
4. Facility owner (Non-L.U.S.T.)
Date
T
iment agency 3. Private (3rd) party
5. Other:
RECOMMENDED ACTION
(MULTIPLE CHOICES POSSIBLE)
1. Investigation complete
0. Initiate/complete cleanup
5. Drilling support
7. Confirm leak
2. Continue investigation
4. Long-term remedial action
6. Issue NOV
8. Monitoring plan
Comments 7 S` /s o r�ai
a s
wi//
71
D
r
�i
1. Responsible Party
Site Priority
CLEANUP LEAD
Ranking
2. State
D.E.M. Regional Contact
Signature
., ,
Date
GW-61 Revised 5/89

POLLUTION INCIDENT/U.S.T, LEAK REPORTING
LOCATION OF INCIDENT
7 1/2 Min. Quad Name
LCL: Deg: Min: Sec:
350 12100 I r
L4aQ.: Deg: Min : Sec
Five Min. Quad Number
Draw Sketch of Area
so c�•� (�, f31 �rc1
K
tv
V
/V
Sketch Should Identify The Following:
'
1. Pollutant Source(s) { 2. Impacted and
Threatened Water Supplies
3. Direction of Overland Flow 4. Significant
Recharge and Discharge Features
5. Relative Physical Structures (roads,
-
buildings, etc.)
5. North Arrow
7. Scale