MO-27728_47042_CA_UST-61_20200513_24-Hour Release and UST Leak Reporting Form

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)
Facility ID Number
Incident# Risk (H,I,L,U)
Confirmed GW Contamination? (Y/N)
Date Leak Discovered i
Received On Received By
Confirmed Soil Contamition ?(YIN)
Y
Comm/Non-Commercial? I Mi -LAN
Reported by (circle one): Phone, Fax or Report
Samples Taken?(Y/N)
Reg/Non-regulated?
Region
Free Product? (Y/N) UP, If Yes, State Greatest
Thickness M A
INCIDENT DESCRIPTION
Incident Name: P�(f 1..�,➢�
Address:
County: '`'` 1• x UJtz
Regional Office (circle one): Asheville, oore Fayelleville,
CitylTown: (!x \ q Zip Code:1,017 cp
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): '� r+- 1 C#` r5Lj51 Longitude (decimal degrees) : — 7� ,?_t7 301 S* IObtained
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 recoveryefforts, initial responses conducted, impacts to rece tors
[]Topographic map
❑GIS Address matching
VOther
wand
t i� iarr�+C�vtS (J S 1.44, G A 7TTwiPsa,.i
ctC�L�1i R C g�<j� t r� a t
lt�
1 t i
❑Unknown
Describe location:
f)T- i2 56()M jkn. J icy 5 N"
1.AS . +„ r-t L u .� f?'h t �.PG
JUt—jpL IT ,t— A:51,A
HOW RELEASE WAS DISCOVERED (Release code)
(Check one)
❑Release Detection Equipment or Methods ❑Visual/Odor El 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 CB Petroleum ❑ Gasoline/ Diesell ❑ Diesel/Veg. Oil
Kerosene Blend
❑ Piping ❑ Overfill ❑ Non -Petroleum
Heating Oil ❑ Vegetable Oil 100%
❑ Dispenser ❑Corrosion ❑Both
❑ Other Petroleum ❑ E10 - E20
❑ Submersible Turbine Pump ❑ Physical/Mechanical Location Products
❑ E21 - E84
Damage
❑ Delivery Problem (Check one) ❑ Metals
❑ Install Problem ❑ E85 - E99
❑ Spill Bucket ❑ Other Inorganics e
❑ Other ❑Facility [:]Ethanol 100 /e
❑ Other INUnknown buResidence ❑ Other Organics ❑ E01 - E09
❑ Unknown
❑Other
Definitions presented on reverse
Definitions presented on reverse
Ownership
1. Municipal 2. Military 3. Unknown 4. Priva 5. Federal 6. County 7. State
Operation Type---�----
1. Public Service 2. Agricultural 3�_Reside I-'4• Education/Relig. 5. Industrial 6. Commercial 7, Mining
UST Form 61 (02/19) ' -I-

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
Point of Contact
Address
City
State
Zip Code
Telephone Number
UST SYSTEM OPERATOR
UST Operator/Company ( j
CUy`1'
Address
City
State
Zip Code
Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
Address
UPCCUe G LLC
�
W)L-L leo
City
State
Zip Code
Telephone Number
"Cty J&1,�.Tt a
W G
Z-S 0
?c%l 3 3`�
Draw Sketch of Area (showing two major road intersections) or Attach Map
Person Reporting Incident
Company �r
Telephone Number? l L41-1 SU
Title ��UL -
Address
Date S
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

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SGS N
Technical Report for
Thompson Geological
2134 Lanier Ave, Charlotte, NC
SG S Job Number: FA71241
Sampling Date: 12/26il 9
Report to:
Thompson Geological
2411 Lawyers RdW
Indian Trail., NC 28079
phihpthomCd,'msn. coin
IATTN: Phil Thompson
Total number of pages in report:
C,
Teet results contained within this data pack -age meet the requirements ZtfinBrice. M.S.
ol'the Natimtal bytironmewal Laborawry Accreditation Pmenurl General Manager
and Or stare spccifie certification prograins as applicable,
Client Service contact: Muna Mohammed 407-425-6700
Certifications : FUE93 3516), I.A(03051). KS(Eill 32277). IL(200063). NC(573), NAH-0,02). N1Y( 12022), SC(0603MOI)
Dal) ELAP(ANNAB ) ' 229). AZ(AZO806). CA(29-3 37). TX(I"I04704404). M69-033 573 ), VA(460177).
AK. Alt- LA. KY, XIA. MS. ND. NIL NV, OK. OR- UT, NVA, WV
I his report shalt [lot lie reproduced, except in its entirety, vvilhoul the ttriiten approval ol'SGS.
Test results relate only tea samples nalyzcd,
rh America Ine, - 4408 Vineland Road - Suite C-Fa Orlando. Fl, 32911 - vel: 407425-6700 - fax: [phone]

Section 1: Sampi Stxnx .>d>..>.b.>,....... .................... ,...>#,.,.>,......Q,,,,.,,a,<,»,>.>,a,>><,...,.>..
Section 2: C e °at r C� i�-Inance
Section 4. S ijn ��� �a���.���� ...........„
4.1, FA71241-11 CS-1........................ 7
Chain of C Cody ....... 9
Method Blank Summary ............................................
........ ...................... ........ 12
j Summary. . ... ..................................._.....
Blank Spik................,.............
....................
Matrix Spire/Matrix Spike Duplicate Summary......................................................... 14

SGS North Amcliica Inc.
Sample Summary
Thompson G4olo--ical
I —
2134 Lanier A, ve, Charlotte, NC
Job No: FA71241
Sample 'Clollected Alatrix Client
Number I Date Tide By Received Code Type Sample ID I
FA71241-1 1�126119 15:0OPT 12,i2WI9 SO Soil
CS-1
Soil sampics fCP Z7
�rtcd on diy wcight basis unless otherwisc indicated on result pagc,

Client:
Site,
SAMPLE DELIXTRY GROJUP CASE NARRATI'VE
Geological
r Ave, Charlotte. NC
Job No: FA71 241
R,4poi lt Date; 1/4/2020 236:29 PM
I Sample was cofleg'ted on 12126n019 and were received at SGS North America Inc - Orlando on 12128/2019 properly preserved, at 2.1
Deg. C and intact. Pis Sample received an SGS Orlando job number of FA71241. A listing ofthe Laboratory Sample ID, Client Sample
ID and dates of collIction are presented in the Results Summary Section. Except as noted below, all method specified calibrations and
quality control per"'Irmance criteria were met for this jab. For more information, please refer to QC summary pages.
GC/LC Semi- olatiles By Method SW846 8015C
Matrix. SO Batch ID: OP78358
All samples wei e extracted within the recommended method holding time.
All samples wl# analyzed -within the recommended method holding time.
Sample(s) FA71241-IMSD. FA71241-IMS, FA71241-IMSD were used as the QC samples indicated.
All meth
od s for this batch meet method specific criteria.
e _Ik , C,
Mal overy(s) for TPH (CI0-C28) are outside control limits. Outside control limits due to high level in sample
relative to spikel amount.
Matrix Spike DPlicate Recovery(s) for TPH (CIO-C29) are outside control limits. Probable cause is due to matrix interference.
RPD(s)for MS�Pfar TPH (C10-C28) are outside control limits for sample OP783S8-MSD. Probable cause is due to sample
Sample(s) FA71241-1 have surrogates outside control limits.
i
Sample(s) 1241-1 are outside limit-, due to dilution.
VA7124 I- I : Spike recovery indicates possible matrix interference and/or sample non-homogencity.
FA71241-1 for 0-Terphertyl: Outside control limits due to dilution,
General Chenfistry By Method SM19 254OG
Matrix:, So Batch ID: GN84004
I
Sample(s) rA71241-IDUP were used as the QC samples for Solids, Percent.
SGS Orlando certifi . that this report meets fhe project requirements for analytical data produced for the samples as received at SGS
Orlando and as statt d an the COC. SGS Orlando certifies that the data meets the Data Quality Objectives for precision, accuracy and
completeness as speificit in the SGS Orlando Quality Manual except as noted above. This report is to be used in its entirety. SGS Orlando
is not responsible fo any assumptions of data quality if partial data packages are used.
Narrative prepared
Kravitz. Client Services (Signature on File)

Summary f Hits Page I of I
Job Number: IFA71241
Account: hompson Geological
Project: 2134 Lanier Ave. Charlotte. NC
Collected: 12t26119
Lab Sample ID Client Sample ID Result/
Analvte Qual RL MDL Units INlethod
FA71241-1 1 CS-1
TPH (C I O-C28)' r 12500 1600 800 m(yik,a SW846 8015C
(a) Spike rccovcly indicates possible matrix interference andfor sample non -homogeneity.

Sample Results
Report of Analysis

SGS Norih.Arnefica Inc.
Report of Analysis
Page I of I
Client Sample 11):
CS- I
Lab Sample fl)
FA71241 -1
Date Sampled:
12126!19
Matrix*
SO - Soil
Date Received.
12L28/'19
Method:
SW846 8015C SW846 3546
Percent Solids:
78.2
Project:
2134 Lanier Ave, Charlotte, NC
F*I ID
DPI Analyzed By
Prep Date Prep Batch
Analvtical Batch
Run 41 J`�1101 4 7 8 5 D 250 01/02/20 15.43 SJL
12i30!19 10:30 OP78358
GJJ 1013
Run ',L1
Run "I
Run #2
CAS No.
Ini * I Weight Final Volume
20.ag 1.0 ml
CAS No. St
84- 15- 1 0-
(a) Spike recovc
(b) Outside cont
pound Result RL MDL Ulnits Q
(C I 0-C2 8) 12500 1600 800 nigika
agate Recoveries Run# I Run# 2 Limits
phenyl 0% b 56-1 —12%
indicates possible matrix interference and/or sample non-boniogencity,
limits due to dilution.
ND = Not detected MDL = Method Detection Limit J = Indicates an estimated value
RL — RcporfingiLiinit
i B Indicates analyre found in associated method blank
E — Indicates vilue cxcceds calibration rau.-c N Indicates presumptive evidence of a compound

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Harmon Environmental. PA
615 Bruce Thomas Road
Monroe, North Carolina 28112
May 13, 2020
Ms. Trudy Beverly, P.G.
NC Department of Environmental Quality
610 East Center Avenue, Suite 301
Mooresville, North Carolina 28115
Re: Receptor Survey — Upton Enterprises, LLC Property
2134 Lanier Avenue, Charlotte, North Carolina
Incident No. Pending
Project No. 843-01
Ms. Beverly:
704-292-4527
harmonenvironmental.com
In conjunction with the scheduled tank closure activities associated with this project, On May 12,
2020, Harmon Environmental, PA personnel conducted a receptor survey within 150 feet of the
former underground storage tank (UST) basin. No water supply wells were observed within this
radius.
Call or email if you have any questions or require any additional information.
Sincerely,
Harmon Environmental, PA
A IVO
tjn
Richard L. Harmon, PG
President/Principal Hydro eolo i
cc: Butch Upton

Beverly, Trudy
From: Beverly, Trudy
Sent: Tuesday, May 26, 2020 9:25 AM
To: Rick Harmon
Subject: RE: [External] 2134 Lanier Avenue Charlotte NC Heating Oil UST - Upton Enterprises,
LLC - UST Incident #47042
Good Morning Rick,
See site info below. FYI, I'll be on leave June 1-51n
Site Name: Upton Enterprises, LLC
UST# MO-27728
Incident #47042
Address 2134 Lanier Avenue, Charlotte
Have a great day,
Trudy
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
D-1E North Carolina Department of Environmental Quality
uepirLm n[o7—Lmmrvnmenta4arrw„` UST Section, Mooresville Regional Office
704.235.2182 (Office)
Trudy.13everlykncdenr. 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: https://deq.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: hitps://deg.nc.gov/about/divisions/waste-management/ust/ast-proeram
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httns://deo.nc. eov/about/divisions/waste-manaeement/waste-manaeement-rules-data/waste-manaeement-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):
htt2s://deg.nc.gov/about/divisions/waste-management/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
httys:Hfiles.nc.eov/ncdea/Waste%2OMana¢ement/DWM/UST[WhatsNew/Final-Electronic-Document-Submittal-Policy.odf
hiips:Hfiles.nc. gov/ncdeq/Waste%2OManagement/D WMiUST/Corrective%2OAction/UST%2Ofile%20names%20for%2OLaserfiche.docx
From: Rick Harmon [maiIto: [e-mail]]
Sent: Tuesday, May 26, 2020 8:55 AM
To: Beverly, Trudy <[e-mail]>
Subject: Re: [External] 2134 Lanier Avenue Charlotte NC Heating Oil UST
��n
rnal email. Do not click links or open attachments unless you verify. Sen a suspicl use toc. ov
Ms. Beverly:
Have you assigned an Incident No. to this project? My client has requested I proceed with a NORP.
Call or email to discuss.

Richard Harmon, P.G.
Harmon Environmental, PA
615 Bruce Thomas Road
Monroe, NC 28112
704-292-4527
harmonenvironmental.com
On Thursday, May 14, 2020, 06:52:51 AM EDT, Beverly, Trudy <trudy.beverly(c�ncdenr.gov> wrote:
Received.
Have a great day,
Trudy
D, E
ucnarua.�r � t��,a,tu awm
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: htips:Hdeq.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: hns://deq.nc.gov/about/divisions/waste-management/ust/ast-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
hfps:Hdeq.nc.govlabout/divisions/waste-managementlwaste-management-rules-datalwaste-mana eg ment ig s maps
File Review Procedures:
https://deq.nc.gov/about/divisions/waste-management/ustlfile-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
https:Hdeq.nc.gov/about/divisions/waste-management/laserfiche

Document Submittal & UST File Names for Laserfiche Policies:
https://files.ne.2oy/ncdeq/Waste%20Manallement/D W MIUSTIW hatsNew/Fin al-Electronic-Document-Submittal-Poliev.pdf
https:llfiles.nc.�,ovincdeq/Waste%20ManagementIDWM[USTICorrective%2OAction[UST%2Ofile%20names%20for%2OLaserfiche.doex
From: Rick Harmon jmailto:harmonenv(a)-yahoo.com]
Sent: Wednesday, May 13, 2020 2:42 PM
To: Beverly, Trudy <trudy.beverly(a)ncdenr.gov>
Cc: Butch Upton <butch.upton(a)-housemaster.com>
Subject: [External] 2134 Lanier Avenue Charlotte NC Heating Oil UST
External email. Do not click links or open attachments unless you verify. Send all suspicious email as an
attachment to
Ms. Beverly:
Attached please find a UST-61 Form for a former heating oil tank discovered at 2134 Lanier Avenue in Charlotte, North
Carolina. This UST is located in a narrow strip of ground between the residential structure and the detached
garage. Thompson Geologic hand augered a soil sample from adjacent to the tank in December 2019. Analytical results
indicated the presence of diesel range petroleum compounds at 12,500 mg/kg. DeBruhl Environmental Excavating, Inc.
has been retained by the land owner to remove the fluids from the tank and if possible, remove the tank from the
site. Based on the proximity of the house and garage to the UST, initial abatement excavation activities are not
feasible. Harmon Environmental, PA has been retained by the land owner to assist in preparing a Notice of Residual
Petroleum for the the site. To initiate this process, on May 12, 2020, Harmon Environmental, PA conducted a receptor
survey within 150 feet of the UST. Attached please find a letter summarizing these activities.
Please advise us of the Incident ID number assigned to this project. Call or email of you have any questions or require
any additional information.
Richard Harmon, P.G.
Harmon Environmental, PA
615 Bruce Thomas Road
Monroe, NC 28112
704-292-4527
harmonenvironmental.com