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Home My WebLink AboutMO-7444_36096_CA_UST-61_20200125_24-Hour Release and UST Leak Reporting Form Auto Diesel Transition SumpUST-61 24-Hour Release and UST Leak Reporting Form. For Releases This form should be completed and submitted to the UST Section's regional office following a known or suspected release from an underground storage tank (UST) system. This form is required to be submitted within 24 hours of discovery of a known or in NC suspected release (DWM USE ONLY) Suspected Contamination? (Y/N) N Facility ID Number 0000011084 Incident # Risk (H,I,L,U) Confirmed GW Contamination? (Y/N) N Date Leak Discovered 1/24/20 Received On Received By Confirmed Soil Contamination ?(Y/N) N Comm/Non-Commercial? Comm Reported by (circle one): Phone, Fax or Report Samples Taken?(Y/N) N Reg/Non-regulated? Reg Region Free Product? (Y/N) Y If Yes, State Greatest Thickness inch or 2 in Sump INCIDENT DESCRIPTION Incident Name: Pilot Travel Center #56 Address: 2825 Lane Street County: Cabarrus Regional Office (circle one): Asheville, Mooresville, Fayetteville, City/Town: Kannapolis Zip Code: 28081 Raleigh, Washington, Wilmington, Winston-Salem Latitude (decimal degrees): 35 29 53.20 N Longitude (decimal degrees) : 80 33 39.54 W Obtained by: ❑GPS Briefly describe suspected or confirmed release: (including but not limited to: nature of release, date of release, amount of release, amount of free product present and recovery efforts, initial responses conducted, impacts to receptors) ❑Topographic map Diesel and water observed in auto diesel transition sump. Once liquids removed observed leak in piping. Piping isolated to stop leak and repairs scheduled for afternoon o ere was no evidence ot product eaving sump. Hydrostatic test of sump and line testing will be conducted at conclusion of piping repair. QGIS Address matching ❑Other ❑Unknown Describe location: Reason for service call to locate issue was slow flow on diesel pumps. During service call loss of pressure was detected on auto diesel line. US Tank brought in to locate leak. Leak in transition sump found during pressure testing. HOW RELEASE WAS DISCOVERED (Release code) (Check one) QRelease Detection Equipment or Methods ❑Visual/Odor ❑Groundwater Contamination ❑During UST Closure/Removal ❑Water in Tank ❑Surface Water Contamination ❑Property Transfer ❑Water Supply Well Contamination ❑Other (specify) SOURCE OF CONTAMINATION Source of Release Cause of Release Type of Release Product Type Released (Check primary source) (Check primary cause) (Check one) (Check primary product type released) ❑ Tank ❑ Spill 0 Petroleum 0 Gasoline/ Diesel/ ❑ Diesel/Veg. Oil Q Piping ❑ Overfill ❑ Non -Petroleum Kerosene Blend Heating Oil ❑ Vegetable Oil 100% ❑❑ Dispenser Corrosion Both ❑❑ ❑ Other Petroleum ❑ E10 — E20 ❑ Submersible Turbine Pump Q Physical/Mechanical Location Products ❑ (Check one) Metals Delivery Problem Damage ❑ E21 — E84 ❑ ❑ Install Problem ❑ E85 — E99 ❑ Spill Bucket ❑ Other Inorganics o ❑ Other ❑Facilit Y [:]Ethanol 100 /o ❑ Other ❑ Other Organics ❑ Unknown ❑Residence ❑ E01 — E09 ❑ Unknown ❑Other Definitions presented on reverse Definitions presented on reverse 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 UST Form 61 (02/19) 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 Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary) 1. 2. 3. UST SYSTEM OWNER UST Owner/Company Pilot Travel Centers, LLC Point of Contact Address Keith Carlton, Environmental Project Manager 5508 Lonas Road City State Zip Code Telephone Number Knoxville TN 37909 864-474-3106 UST SYSTEM OPERATOR UST Operator/Company Address Pilot Travel Centers, LLC 5508 Lonas Road City State Zip Code Telephone Number Knoxville TN 37909 864-474-3106 LANDOWNER AT LOCATION OF UST INCIDENT Landowner Address Pilot Travel Centers, LLC 5508 Lonas Road City State Zip Code Telephone Number Knoxville TN 37909 864-474-3106 Draw Sketch of Area (showing two major road intersections) or Attach Map See attached site map Person Reporting Incident R. Wagner Company Apex Companies, LLC (on behalf of Pilot) Telephone Number 540-563-4920 Title Sr. Program Manager Address 7724 Garland Circle, Roanoke, VA 24019 Date 1/25/20 UST Form 61 (02/19) Page 2 of 2 Definitions of Sources Tank: means the tank that stores the product and is part of the underground storage tank system Piping: means the piping and connectors running from the tank or submersible turbine pump to the dispenser or other end -use equipment (Vent, vapor recovery, or fill lines are excluded.) Dispenser: includes the dispenser and the equipment used to connect the dispenser to the piping (e.g., a release from a suction pump or from components located above the shear valve) Submersible Turbine Pump (STP) Area includes the submersible turbine pump head (typically located in the tank sump), the line leak detector, and the piping that connects the submersible turbine pump to the tank Delivery Problem: identifies releases that occurred during product delivery to the tank. (Typical causes associated with this source are spills and overfills.) Other: serves as the option to use when the release source is known but does not fit into one of the preceding categories (e.g., for releases from vent lines, vapor recovery lines, and fill lines) Unknown: identifies releases for which the source has not been determined Definitions of Causes Spill: use this cause when a spill occurs (e.g., when the delivery hose is disconnected from the tank fill pipe or when the nozzle is removed from the dispenser) 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) Physical or Mechanical Damage: use for all types of physical or mechanical damage, except corrosion (e.g., puncture of tank or piping, loose fittings, broken components, and components that have changed dimension) Corrosion: use when a metal tank, piping, or other component has a release due to corrosion (e.g., for steel, corrosion takes the form of rust) Installation Problem: use when the problem is determined to have occurred specifically because the UST system was not installed properly Other: use this option when the cause is known but does not fit into one of the preceding categories (e.g., putting regulated substances into monitoring wells) Unknown: use when the cause has not been determined UST Legend B-10,000-gallon Gasoline C - 15,000-gallon Gasoline A- 4,000-gallon Auto Diesel D - 20,000-gallon Diesel E - 20,000-gallons Diesel DR.: DRY DATE: Oct. 2019 CK.: CLC CAP APPD.: RSW Implementation SCALE: 1 = 6T APEX PROJ. NO.: 768490.030 Incident #3609E www.apexcos.com Al, APEX 7724 Garland Circle Roanoke, VA24019 Phone:540-563-4920 Site Plan Pilot Station #56 2825 Lane Street Kannapolis, North Carolina FIGURE No. 2 A ,,i,, s'�; :Y {X' � ,s� � -t /� i� a \ '- .+ •• q, - - i �' �'• �.. � ''3� :� L . t +�• � ,, ��,,� . ti — . ^'s. t� � r i i s r I•:.r i At •E-f. lot •, 1C°.fv�t.r.`'1S+'.0 t ( q e4 �P r Al ry NO 10 At sti ait 0 7T w ANN- • i UST-6F/23B Triennial UST Containment Sump / UDC Integrity Testing D_EQ Page 1 (Full height hydrostatic or vacuum test) ➢ 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 Owner / Operator Name Facility Name Facility ID#: PILOT TRAVEL CENTERS, LLC PILOT TRAVEL CENTERS 056 00-0-0000011084 Facility Street Address Facility City County 2825 LANE STREET KANNAPOLIS Cabarrus TESTING CONTRACTOR INFORMATION Company Name Phone E-mail Address JONES & FRANK 704-393-8542 MSTODDARD@JONES-FRANK.COM I certify, under penalty of law, that the testing data provided on this form documents the UST system equipment was tested in accordance with the manufacturer's guidelines and the applicable national industry stan rds listed in 15A N9fC 2N .0406 and/or 15A NCAC 2N .0900. MICHAEL STODDARD IA4"_4 Signature of person4Wnducting test � 01/25/2020 Print Name of person conducting test Test Date Identify UDC/sump (By ❑Dispenser ❑Dispenser ❑Dispenser ❑Dispenser ❑Dispenser ❑Dispenser Dispenser No. or Tank Number, Tank Size, Stored Product, e.g. ®Tank ❑Tank ❑Tank ❑Tank ❑Tank ❑Tank #1 10k Regular STP, Disp 112, #: #2 20K #: #: #: #: #: etc.) PIPING SUMP Transition sumps should be listed above as "TS-XX" (with XX= sump ID#) ® FRP ❑ FRP ❑ FRP ❑ FRP ❑ FRP ❑ FRP Sump Material ❑ Plastic ❑ Plastic ❑ Plastic ❑ Plastic ❑ Plastic ❑ Plastic M Hydrostatic ❑ Hydrostatic ❑ Hydrostatic ❑ Hydrostatic ❑ Hydrostatic ❑ Hydrostatic Test Type ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum Indicate units for all measurements Liquid and debris removed from M Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No sump? Visual inspection (No cracks, loose parts or separation of the M Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail containment sum Sump Depth in inches 24 INCHES Height from sump bottom to top of highest penetration or sump 12 INCHES sidewall seam in inches Wait time between applying 15 MINUTES vacuum/water and start of test Begin i End Test Time 15:00 i 16:00 i i i i i (minimum test time: 1 hour) Begin i End values (inches) 21 IN i 21 IN i i i i i 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 ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) Testing following product line leak found inside containment sump. Sump passed hydrostatic tests. Date next Containment Sump/UDC integrity test due (required every 3 years) 01/25/2020 NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION 3/2019 1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE (919) 707-8171 FAX (919) 715-1117 http://www.wastenglnc.org UST-6F/23B Triennial UST Containment Sump / UDC Integrity Testing Q� MD. Page 2 Low Liquid Level Test) 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 can be tightness tested every three (3) years in accordance with the NCDEQ Low Level Hydrostatic Integrity Test Procedures which can be found on the UST section website at https:Hdeq.nc.gov/about/divisions/waste-management/ust/forms. This method cannot be used for the installation testing of containment sumps. ➢ 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. ➢ 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. ➢ Attach all setup reports (e.g. Veeder-Root: Output Relay Setup, Incon: Main console setup) for the sensor alarms positive shut -down to this form. If the dispenser has a standalone sensor to shut -down the dispenser then annotate on the test form in the comments section. UST FACILITY Owner / Operator Name Facility Name Facility ID#: Facility Street Address Facility City County TESTING CONTRACTOR INFORMATION Company Name Phone E-mail Address I certify, under penalty of law, that the testing data provided on this form documents the UST system equipment was tested in accordance with the manufacturer's guidelines, the applicable national industry standards listed in 15A NCAC 2N .0406 and/or 15A NCAC 2N .0900, or another method approved by NC DEQ. Print Name of person conducting test Signature of person conducting test Test Date Identify UDC/sump (By ❑Dispenser ❑Dispenser ❑Dispenser ❑Dispenser ❑Dispenser ❑Dispenser Dispenser No. or Tank Number, Tank Size, Stored Product; e.g. ❑Tank ❑Tank ❑Tank ❑Tank ❑Tank ❑Tank #1 10k Regular STP, Disp 112, #: #: #: #: #: #: etc. Transition sumps should be listed above as "TS-XX" (with XX= sump ID#) ❑ FRP ❑ FRP ❑ FRP ❑ FRP ❑ FRP ❑ FRP Sump Material ❑ Plastic ❑ Plastic ❑ Plastic ❑ Plastic ❑ Plastic ❑ Plastic Indicate units for all measurements Liquid and debris removed from ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No sump? Is sensor 2" or less from lowest ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No portion of sump bottom? Visual inspection (No cracks, loose parts or separation of the ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail containment sump) Did sensor alarm when tested? ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No If sensor alarms, did the STP and/or dispenser shut-off? Note for dispenser sensors all ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No product types in the dispenser must be disabled. Level above bottom of sump where sensor alarms. (inches) Wait time between applying water and start of test Begin i End Test Time i i i i i i (minimum test time: 1 hour) Begin i End values (inches) i i i i i i Pass/Fail criteria: Any No or Fail in the above, the sump fails the test . Hydrostatic: Water level drop of 1/8 inch or more fails the test. Test Result ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ 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 3/2019 1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE (919) 707-8171 FAX (919) 715-1117 http://www.wasteagtnc.org UST-6F/23B Triennial UST Containment Sump / UDC Integrity Testing Page 3 (Dri-sUMpTM Test) 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 can be tightness tested every three (3) years in accordance with the Dri-sumpTM testing method. ➢ 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. ➢ 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 Owner / Operator Name Facility Name Facility ID#: Facility Street Address Facility City County TESTING CONTRACTOR INFORMATION Company Name Phone E-mail Address I certify, under penalty of law, that the testing data provided on this form documents the UST system equipment was tested in accordance with the manufacturer's guidelines, the applicable national industry standards listed in 15A NCAC 2N .0406 and/or 15A NCAC 2N .0900, or another method approved by NC DEQ. Print Name of person conducting test Signature of person conducting test Test Date Tester Certification #: Equipment Certification #: Tester Certification Expiration: Equipment Certification Expiration: Identify UDC/sump (By ❑Dispenser ❑Dispenser ❑Dispenser ❑Dispenser ❑Dispenser ❑Dispenser Dispenser No. or Tank Number, Tank Size, Stored Product; e.g. ❑Tank ❑Tank ❑Tank ❑Tank ❑Tank ❑Tank #1 10k Regular STP, Disp 112, #: #: #: etc. Transition sumps should be listed above as "TS-XX" (with XX= sump ID#) ❑ FRP ❑ FRP ❑ FRP ❑ FRP ❑ FRP ❑ FRP Sump Material ❑ Plastic ❑ Plastic ❑ Plastic ❑ Plastic ❑ Plastic ❑ Plastic Construction ❑ SW ❑ DW ❑ SW ❑ DW ❑ SW ❑ DW ❑ SW ❑ DW ❑ SW ❑ DW ❑ SW ❑ DW Liquid and debris removed from ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No sump? Visual inspection (No cracks, loose parts, open penetrations ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail or separation of the containment sum Is groundwater above bottom of ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No sump? seconds mm WC seconds mm WC seconds mm WC seconds j mm WC seconds mm WC seconds mm WC VST #1 Communication VST #2 Communication (if applicable) VST communication test should be i 2.3 mm WC in 5-10 seconds. Attach a map of the VST locations for each sump to the results. Test length in seconds DW Primary wall or SW Laser Verification ❑ Dot (Pass) ❑ Dot (Pass) ❑ Dot (Pass) ❑ Dot (Pass) ❑ Dot (Pass) ❑ Dot (Pass) (DW Primary wall or SW) ❑ Line (Fail) ❑ Line (Fail) ❑ Line (Fail) ❑ Line (Fail) ❑ Line (Fail) ❑ Line (Fail) Test length in seconds (Secondary wall, if DW Laser Verification ❑ Dot (Pass) ❑ Dot (Pass) ❑ Dot (Pass) ❑ Dot (Pass) ❑ Dot (Pass) ❑ Dot (Pass) (Secondary wall, if DW) ❑ Line (Fail) ❑ Line (Fail) ❑ Line (Fail) ❑ Line (Fail) ❑ Line (Fail) ❑ Line (Fail) Pass/Fail criteria: Must pass visual inspection. Laser result must be a laser -dot (pass). If the first test fails, then conduct a second test entering results in another column. Test is not valid if liquid or debris was not removed from sump. Final Test Result ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ 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 3/2019 1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE (919) 707-8171 FAX (919) 715-1117 http://www.wasteagtnc.orq UST-6F/23B Triennial UST Containment Sump / UDC Integrity Testing Page 4 (DPleak° Test) 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 can be tightness tested every three (3) years in accordance with the DPleak° sump testing method. ➢ 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. ➢ 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 Owner / Operator Name Facility Name Facility ID#: Facility Street Address Facility City County TESTING CONTRACTOR INFORMATION Company Name Phone E-mail Address I certify, under penalty of law, that the testing data provided on this form documents the UST system equipment was tested in accordance with the manufacturer's guidelines, the applicable national industry standards listed in 15A NCAC 2N .0406 and/or 15A NCAC 2N .0900, or another method approved by NC DEQ. Print Name of person conducting test Signature of person conducting test Test Date Tester Certification #: Identify UDC/sump (By ❑Dispenser ❑Dispenser ❑Dispenser ❑Dispenser ❑Dispenser ❑Dispenser Dispenser No. or Tank Number, Tank Size, Stored Product; e.g. ❑Tank ❑Tank ❑Tank ❑Tank ❑Tank ❑Tank #1 10k Regular STP, Disp 112, #: #: #: #: #: #: etc. Transition sumps should be listed above as "TS-XX" with XX= sump ID# ❑ FRP ❑ FRP ❑ FRP ❑ FRP ❑ FRP ❑ FRP Sump Material ❑ Plastic ❑ Plastic ❑ Plastic ❑ Plastic ❑ Plastic ❑ Plastic Construction ❑ SW ❑ DW ❑ SW ❑ DW ❑ SW ❑ DW ❑ SW ❑ DW ❑ SW ❑ DW ❑ SW ❑ DW Liquid and debris removed from ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No sump? Visual inspection (No cracks, loose parts, open penetrations El Pass El Fail El Pass El Fail El Pass El Fail El Pass El Fail El Pass El Fail El Pass El Fail or separation of the containment sum ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail North/Rear ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail East/Right ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail South/Front ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail West/Left ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail Floor ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail Electrical/Pen #1 ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail STP/Turbine/Pen#2 ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail Pen #3 / ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail Pen #4 / ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ N/A ❑ N/A Pass/Fail criteria: Must pass visual inspection. Test is not valid if liquid or debris was not removed from sump. No areas of sump that fail. LDT test report with addendums attached I ❑ Yes ❑ No Final Test Result I ❑ Pass ❑ Fail I ❑ Pass ❑ Fail I ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail Comments — (include information on repairs made priorto testing, and recommended follow-up forfailed tests) Date next Containment Sump/UDC integrity test due (required every 3 ears NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION 3/2019 1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE (919) 707-8171 FAX (919) 715-1117 htto://www.wastengtnc.org Beverly, Trudy From: Beverly, Trudy Sent: Monday, January 27, 2020 9:28 AM To: Robert Wagner Subject: RE: [External] RE: Pilot 56 Kannapolis Release Reporting Great. Thanks for the update, Trudy � Qi�- 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. 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: hops://deq.nc.gov/about/divisions/waste-manaaement/ust Branch's Above Ground Storage Tanks Website Address: ht!ps:Hdeg.nc.gov/about/divisions/waste-management/ust/ast-proeram INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES: httns://deo.nc. eov/about/divisions/waste-management/waste-management-rules-data/waste-management-eis-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): hops: //deg.nc. gov/about/divisions/waste-management/laserfiche Document Submittal & UST File Names for Laserfiche Policies: https:Hfiles.nc. gov/ncdeg/Waste%20Management/D WM/UST/Corrective%2OAction/Electronic%2ODocument%2OSubmittal%2OMemo%2OUpdate.pdf https:Hfiles.nc. gov/ncdeq/\Vaste%2OManagement/D WM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx From: Robert Wagner [mailto:RWagner@apexcos.com] Sent: Monday, January 27, 2020 8:33 AM To: Beverly, Trudy <trudy.beverly@ncdenr.gov> Subject: [External] RE: Pilot 56 Kannapolis Release Reporting External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to report.spam@nc.Eov Trudy all repairs have been made and the line is scheduled for testing today. Attached is the passing hydro test form. Also attached a picture of the fitting that busted in sump as well as a pic of the repaired line. Robert Wagner Sr Program Manager 7724 Garland Cir Roanoke, VA 24019 O)140-563-4920 x4451 M) 140-798-1494 APEX ED Add me to your contact list! am Wu1 ENR Top 30 All -Environmental Firm Im CIE We've moved! Our new address is 7724 Garland Cir, Roanoke, VA 24019. Please update your contact list. Thanks. Privacy Notice: This message and any attachment(s) hereto are intended solely for the individual(s) listed in the masthead. This message may contain information that is privileged or otherwise protected from disclosure. Any review, dissemination or use of this message or its contents by persons other than the addressee(s) is strictly prohibited and may be unlawful. If you have received this message in error, please notify the sender by return e-mail and delete the message from your system. Thank you. From: Robert Wagner Sent: Saturday, January 25, 2020 1:39 PM To: 'Beverly, Trudy' <trudy.beverly@ncdenr.gov> Cc: Keith Carlton <Keith.Carlton@ pilottravelcenters.com> Subject: Pilot 56 Kannapolis Release Reporting Trudy Pilot has had a release of diesel fuel into a transition sump for the auto diesel. The release has been stopped and repairs are being made today. Once repairs are complete the sump with be hydrostatically tested and the line will be tested to ensure a good fix. We do not believe that any product left the sump at this time. Please let us know if you have any questions regarding the attached. Thanks, Robert Robert Wagner Sr Program Manager 7724 Garland Cir Roanoke, VA 24019 0)140-563-4920 x4451 M) 140-798-1494 APEXa Add me to your contact list! IPMEGUMM Wrk afe ENR Top 30 All -Environmental Firm om CIE We've moved! Our new address is 7724 Garland Cir, Roanoke, VA 24019. Please update your contact list. Thanks. Privacy Notice: This message and any attachment(s) hereto are intended solely for the individual(s) listed in the masthead. This message may contain information that is privileged or otherwise protected from disclosure. Any review, dissemination or use of this message or its contents by persons other than the addressee(s) is strictly prohibited and may be unlawful. If you have received this message in error, please notify the sender by return e-mail and delete the message from your system. Thank you.