MO-27879_47184_CA_UST-61_20200518_24-Hour Release and UST Leak Reporting Form & Tank Inspection

UST-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)
Facility ID Number
Incident # Risk (H,I,L,U)
Confirmed GW Contamination? (Y/N)
Date Leak Discovered
Received On Received
By
Confirmed Soil Contamination ?(Y/N)
Comm/Non-Commercial?
Reported by (circle one): Phone, Fax or Report
Samples Taken?(Y/N)
Reg/Non-regulated?
Region
Free Product? (Y/N) If Yes, State Greatest
Thickness
INCIDENT DESCRIPTION
Incident Name:
Address:
County:
Regional Office (circle one): Asheville, Mooresville, Fayetteville,
City/Town:
Zip Code:
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees):
Longitude (decimal degrees) :
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
❑ GIS Address matching
❑ Other
❑ Unknown
Describe location:
HOW RELEASE WAS DISCOVERED (Release code)
(Check one)
❑ Release 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 one to indicate primary
(Check one to indicate primary (Check one) (Check one to indicate primary product type
source)
cause) released)
❑ Tank
❑ Spill ❑ Petroleum ❑ Gasoline/ Diesel/ ❑ Diesel/Veg. Oil
❑ Piping
Kerosene Blend
❑Overfill ❑Non -Petroleum
❑ Heating Oil ❑ Vegetable Oil 100%
❑ Dispenser
❑ Corrosion ❑ Both ❑ Other Petroleum ❑ E10 — E20
❑ Submersible Turbine Pump
❑ Physical or Mechanical Products
❑ E21 E84
❑ Delivery Problem
—
Damage Location ❑ Metals
❑ ❑ E85 E99
oOther Inorganics —
❑ Install Problem (Checkne )
❑ Other
❑ Other ❑ Other Organics ❑ Ethanol 100%
❑Facility
❑ Unknown
❑ Unknown ❑ Residence ❑ E01 — E09
Definitions presented on reverse
I Definitions presented on reverse I ❑ Other
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 (02/08) 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:
1.
2.
3.
(Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
UST Owner/Company
UST SYSTEM OWNER
Point of Contact
Address
City
State
Zip Code
Telephone Number
UST SYSTEM OPERATOR
UST Operator/Company
Address
City
State
Zip Code
Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
Address
City
State
Zip Code
Telephone Number
Draw Sketch of Area (showing two major road intersections) or Attach Map
Person Reporting Incident
Company
Telephone Number
Title
Address
Date
UST Form 61 (02/08)
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

Data use subject to license. +TN Scale 1 : 12,000
0 no go 600 800 1000
© DeLorme. Topo North America TM 10. MN (e.,^w) /VNII m
0 3M MO
www.delorme.com 1" = 1.000.0 ft Data Zoom 14-3

House
Supply Well
0 10 20 40
T1 = 500-Gallon UST
1 Inch = 20 Feet
PROJECT: Ivan Rodriguez Property
INCIDENT # Pending
LOCATION: 1230 Robinhood Circle
Charlotte Mecklenburg Co.
CRE PROJECT NUMBER: 291622590
CEDAR ROCK
ENVIRONMENTAL, P.C.
FILENAME: 2916-Fig1-UST61.fc7
VERSION DATE: 5/18/20
SITE MAP
FIGURE 1

Cedar Rock
ENVIRONMENTAL
April 30, 2020
Mr. Ivan Rodriguez
1230 Robinhood Circle
Charlotte, NC 28227
CEDAR ROCK ENVIRONMENTAL, P.C.
107 Pioneer Trail
Graham, NC 27253
[phone]
Reference: Inspection of an underground storage tank (UST) located at 1230 Robinhood Circle,
Charlotte, North Carolina
Cedar Rock Project # 291622590
Dear Mr. Rodriguez:
Cedar Rock Environmental, P. C. (Cedar Rock) performed a site inspection on April 27, 2020 at the above
referenced location. The purpose of the inspection was to determine if the UST previously used for storing
heating oil had leaked causing significant contamination of the underlying soils. It is our understanding the
residence was built in 1963 which is most likely when the UST was installed.
An inactive UST was observed to be located parallel to and centered approximately 10.0 feet off the
northern foundation wall and about 14.5 feet west of the northwestern foundation corner of the house. Both
the fill and vent pipes of the UST were observed to be intact. The depth to the top of the UST is
approximately 13 inches below land surface (bls). The UST has a length of about 75 inches with a diameter
of approximately 44.5 inches and a capacity of about 500 gallons. The UST was measured to contain
approximately 256 gallons of fluid. White flagging was installed to mark the ends of the UST. No other
USTs used for storing heating oil were discovered on the property using a metal detector to survey the
outside perimeter of the residence where USTs are usually located. Two copper fuel delivery/return lines
were observed in the basement extending about 30 feet where they were cut and crimped at the former
furnace location. No petroleum odor or staining was observed in the basement.
Once the orientation of the UST was determined, a soil boring was performed at the western end of the tank
using a 3.25-inch diameter stainless steel hand auger. The boring was advanced to a depth of approximately
6.0 feet bls, about 1.2 feet below the bottom of the UST. A strong petroleum odor and discoloration was
observed in the soils from a depth of approximately 3.0 to 6.0 feet bls suggesting significant leakage from
the UST has occurred. The native soils underlying the UST consist of a brownish blue -gray sandy silt.
The property is currently serviced by a municipal water supply; however, a water supply well is located in
the southwest corner of the garage within 150 feet of the petroleum release. Because this well is within
150 feet of the release, the property would be classified as "High Risk" by the State. The property could
be classified as "Low Risk" if the well was properly abandoned.
Based on the results of this investigation, significant contamination of the soils underlying the UST has
been confirmed. Current law (NCGS 143-215.85 (a) and (b)) requires that any significant release of
petroleum be immediately reported to the North Carolina Department of Environmental Quality (DEQ),
Division of Waste Management, Mooresville Regional Office (704-663-1699). According to State law,
upon reporting the release, the current property owner where a release is discovered is identified by the
State as the "Responsible Party" for any State required action relating to the UST leakage. Upon your
request, Cedar Rock will submit a UST-61 form to satisfy the State's notification requirement for the

Mr. Ivan Rodriguez
April 30, 2020
Page 2
release.
Currently, the property cannot be legally conveyed until a Notice of Residual Petroleum (NRP) is filed with
the Mecklenburg County Register of Deeds office pursuant to NCGS 143B- 279.11 (d). The NRP would
contain applicable land use restrictions to minimize the risk of exposure to existing contamination. The
land use restrictions prohibit any disturbance of site soils within a specified radius of the estimated extent
of soil contamination and prohibit the future operation or installation of any water supply wells on the
property. Further, the State will not issue a Notice of No Further Action (NFA) letter to officially close out
the release incident for "High Risk" properties such as this wherein soil or groundwater contamination
exceeding applicable standards remains onsite. The property would be reclassified as "Low Risk" if all
water supply wells within 150 feet of the release were properly abandoned. Once reclassified to "Low
Risk" and an NRP approved, the DEQ would issue a "Conditional" NFA letter to formally close out the
release incident. The "Conditional" provision in the NFA letter will be removed upon receiving a certified
copy of the filed NRP and the completion of Public Notification requirements. Filing the NRP and
abandoning the onsite water supply well within 150 feet of the release would not be required if all soil
contamination exceeding applicable standards is removed.
The State currently will require initial abatement or remedial action regarding the release of heating oil
from a UST on a "High Risk" property. Further, once the presence of the UST and confirmed contaminated
soil is disclosed to other interested parties as required by State law, future buyers, homeowner's insurance
providers, or lenders may also require initial abatement and/or remedial actions relating to the UST prior to
making any commitments towards the property. There also exists a potential for further environmental
impact to the property from continued leakage from the UST.
An NFA letter can be obtained in two different scenarios. Scenario One requires the removal of the UST
and all associated contaminated soil exceeding applicable standards. Scenario Two requires reclassifying
the property to "Low Risk" by abandoning the inactive supply well within 150 feet of the release, filing an
NRP, and performing the Public Notification task.
Attempting to remove the UST and associated contaminated soils is costly, would be disruptive to the
property, and may not result in a clean closure. For these reasons, we do not recommend the removal of
the UST and associated contaminated soils. Instead, we recommend properly abandoning the onsite supply
well to lower the risk classification to "Low Risk" followed by abandonment of the UST. The tank
abandonment would consist of exposing a portion of the UST by hand excavation, cutting a hole about two
feet in diameter on the topside of the UST, removing all tank and fuel line contents, pressure wash cleaning
of the tank interior and filling the tank with an excavatable flowable fill cement slurry. A summary report
signed by a licensed geologist would be generated that would include photographs of each step of the
abandonment process, including a photograph of the interior of the UST to show the UST was properly
cleaned. Cedar Rock can provide this service for a charge of $3,200.00 plus $1.25 per gallon of recovered
fluids. Preparing and filing the NRP and performing the Public Notification requirement will cost an
additional $1,250.00. Cedar Rock would not be responsible for abandoning the onsite water supply well.
If the site remains classified as High Risk, the State will require the removal of the UST and associated
contaminated soils. If required, Cedar Rock can remove the UST including 15 tons of contaminated soil
for a charge of $8,500.00 plus $1.25 per gallon of recovered fluids. Tonnage in excess of 15 tons will be
an added charge at the rate of $120.00 per ton. Based on the observed soil contamination, it is estimated
that at least 20 tons of contaminated soil will require removal. This would include appropriate
environmental assessment, reporting, and site restoration. All work performed would be in accordance with
the recommended practices and procedures outlined in the Underground Storage Tank Section Guidelines
for Site Checks, Tank Closure, and Initial Response and Abatement, Change 9 (February 1, 2019),
published by the North Carolina Department of Environmental Quality, Division of Waste Management,

Mr. Ivan Rodriguez
April 30, 2020
Page 3
UST Section.
Please keep in mind that attempting to remove the UST and all contaminated soils exceeding applicable
standards carries some financial risk because if all the contamination cannot be removed (i.e. if the
contamination extends beyond 17 feet bls), the State will still require abandonment of the water supply
well, filing an NRP and performing Public Notification before issuing an NFA letter.
Attached is an invoice for the site inspection. We appreciate the opportunity to be of service to you. If you
have any questions regarding the content of this report, please call me at 336-376-0394.
Sincerely,
Robert A. Payne, N.C. ricensed Geologist #0970
Attachment
ILr
0970
ffOlt' 4ia,tirti t+

Beverly, Trudy
From: Beverly, Trudy
Sent: Monday, May 18, 2020 2:42 PM
To: [e-mail]
Subject: RE: [External] UST-61 form submission for the Ivan Rodriguez Property, 1230 Robin
Hood Circle, Charlotte, Mecklenburg Co.
Received.
Trudy
Trudy Beverly, L.G.
D-�IE Hydrogeologist, Division of Waste Management
North Carolina Department of Environmental Quality
IFepnrlren[ol Gma'nn mental4w
UST Section, Mooresville Regional Office
704.235.2182 (Office)
Trudy. B everlykncdenr. 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://deg.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: hit2s://deq.nc.gov/about/divisions/waste-management/ust/ast-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httns://dea.nc. gov/about/divisions/waste-management/waste-management-rules-data/waste-management-gis-mans
File Review Procedures:
hops://deq.ne. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
fts://deq.nc.gov/about/divisions/waste-manaizement/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
htti)s:Hfiles.ne.izov/nedeafWaste%2OMana2ement/DWM/UST[WhatsNew/Final-Electronic-Document-Submittal-Policv.l)df
https:Hfiles.nc.gov/ncdeq/Waste%20Management/D WM/UST/Corrective%2OAction/UST%2Ofilc%20names%20for%2OLaserfiche.docx
From: [e-mail] [mailto:[e-mail]]
Sent: Monday, May 18, 2020 2:10 PM
To: Beverly, Trudy <[e-mail]>
Subject: [External] UST-61 form submission for the Ivan Rodriguez Property, 1230 Robin Hood Circle, Charlotte,
Mecklenburg Co.
�� External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
[e-mail]
Hi Trudy
Attached is the UST-61 form for a release from an UST at the above property. Also attached is Cedar Rock's inspection
report and a figure showing the location of the inactive water supply well approximately 50 feet from the release area
inside the garage of the residence. UST removed and soils excavated 5/14/20. We are awaiting the results of laboratory
analyses of soil samples. If you require more information please let me know.
Thanks
Damien Callaghan

Cedar Rock Environmental