MO-28288_47548_CA_UST-61_20201230_24-Hour Release and UST Leak Reporting Form

UST-61
I 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) Y
Facility ID Number N/A
Incident # Risk (H,I,L,U)
Confirmed GW Contamination? (Y/N) N
Date Leak Discovered December 1, 2020
Received On Received By
Confirmed Soil Contamination ?(Y/N) Y
Comm/Non-Commercial? Non-com
Reported by (circle one): Phone, Fax or Report
Samples Taken?(Y/N) Y
Reg/Non-regulated? Non -Reg
Region
Free Product? (Y/N) N If Yes, State Greatest
Thickness
INCIDENT DESCRIPTION
Incident Name: EmpnasisAds. Inc
Address: 1619 North Graham Street
County: Mecklenburg
Regional Office (circle one): Asheville, Mooresville, Fayetteville,
City/Town: Charlotte Zip Code: 28206
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): 35.24386 Longitude (decimal degrees) :-80.83300
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 resent and recoveryefforts, initial responses conducted, impacts to rece tors
❑Topographic map
❑GIS Address matching
DOther
❑unknown
Describe location:
In conjunction with a pending real estate transaction, a Phase I Assessment indicated
the site may have been a historic service station prior to 1980 with evidence that the
may have been removed prior to the UST regulations being promulgated. A soil boring
in the former tank basin indicated petroleum impacted soil remains on -site.
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 primary source) (Check primary cause) (Check one) (Check primary product type released)
❑ Tank ❑ Spill © Petroleum 0 Gasoline/ Diesel/ ❑ DieselNeg. Oil
❑ Piping ❑ Overfill ❑ Non -Petroleum Kerosene Blend
❑Dispenser ❑ Heating Oil ❑ Vegetable Oil 100%
p Corrosion ❑Both
❑ Submersible Turbine Pump ❑ Physical/Mechanical ❑ Other Petroleum ❑ El — E20
Damage Location Products ❑E21 —E84
❑ Delivery Problem (Check one) ❑ Metals
❑ Install Problem ❑ E85 — E99
❑ Spill Bucket
❑ Other Inorganics
❑ Other ®Facility
❑ Other ❑Ethanol 100%
Unknown ❑Residence ❑ Other Organics ❑ 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 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
Unknown
Point of Contact
Address
City
State
Zip Code
Telephone Number
UST SYSTEM OPERATOR
UST Operator/Company
Address
Unknown
City
State
Zip Code
Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
Address
Emphisis Ads, Inc.
P.O. Box 5524
City
State
Zip Code
Telephone Number
Charlotte
INC
28299
Draw Sketch of Area (showing two major road intersections) or Attach Map
See Attached.
Person Reporting IncidentR. Harmon
Company Harmon Environmental, PA
Telephone Number704-292-4527
Title C. �.
Address 615 Brun TM R..d, Ma ., NC 28112
Date 12-3 2020
UST Form 61 (02119)
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 arc 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

Polaris 3G Map — Mecklenburg County, North Carolina
Date Printed: 12/22/2020 3:14:54 PM
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(This map or report is prepared for the inventory of real property within Mecklenburg County and is compiled from recorded deeds, plats, tax maps, surveys,
planimetric maps, and other public records and data. Users of this map or report are hereby notified that the aforementioned public primary information sources
should be consulted for verification. Mecklenburg County and its mapping contractors assume no legal responsibility for the information contained herein. I

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PaceAnalytical
www.pacelabs.com
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
ANALYTICAL RESULTS
Project: 861-01
Pace Project No.: 92507531
Sample: B-2 (4-8) Lab ID: 92507531001 Collected. 11/17/20 09:40 Received: 11/20/20 11:15 Matrix: Solid
Results reported on a "dry weight" basis and are adjusted for percent moisture, sample size and any dilutions.
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
8015 GCS THC-Diesel
Analytical Method: EPA 8015C Modified Preparation Method: EPA 3546
Pace Analytical Services - Charlotte
Diesel Range Organics(C10-C28)
167 mg/kg 6.0 1 11/25/20 12:16
11/30/20 21:27
Surrogates
n-Pentacosane (S)
80 % 32-130 1 11/25/20 12:16
11/30/20 21:27 629-99-2
Gasoline Range Organics
Analytical Method: EPA 8015C Modified Preparation Method: EPA 5030B
Pace Analytical Services - Charlotte
Gas Range Organics (C6-C10)
217 mg/kg 6.3 1 11/23/20 09:59
11/23/20 15:35
Surrogates
4-Bromofluorobenzene (S)
290 % 66-131 1 11/23/20 09:59
11/23/20 15:35 460-00-4
Percent Moisture
Analytical Method: ASTM D2974-87
Pace Analytical Services - Charlotte
Percent Moisture
14.7 % 0.10 1
11/20/20 17:43
Date: 12/01/2020 03:12 PM
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
S5
Page 8 of 14

Beverly, Trudy
From: Beverly, Trudy
Sent: Monday, January 4, 2021 7:24 AM
To: Rick Harmon
Cc: Byron Burns
Subject: RE: [External] UST-61 Form for 1619 North Graham Street Charlotte, NC
Received.
Trudy
Trudy Beverly, L.G.
D_�IE Hydrogeologist, Division of Waste Management
North Carolina Department of Environmental Quality
UST Section, Mooresville Regional Office
IFeparlren[ol Gmn-nnmental4ua, 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/DWM/UST/Corrective%2OAction/UST%20filc%20names%20for%2OLaserfiche.docx
From: Rick Harmon [mailto:[e-mail]]
Sent: Wednesday, December 30, 2020 8:4S AM
To: Beverly, Trudy <[e-mail]>
Cc: Byron Burns <byron@red iron partners.com>
Subject: [External] UST-61 Form for 1619 North Graham Street Charlotte, NC
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Ms. Beverly:
As discussed in a -mails earlier this year, in conjunction with a pending property transfer, a Phase I
Environmental Assessment was conducted on this site by another consultant. This Phase I indicated this site
may have been a historic service station until the late 1970's. Harmon Environmental, PA evaluated the historic
records and determined that a portion of the former tank basin is now located under the North Graham Street
right-of-way. A Geoprobe boring advanced in the on -site portion of the former tank basin on November 17,
2020 indicated the presence of petroleum compounds in the soil. Attached please find a UST-61 Form
addressing this release.

Our client, Mr. Byron Burns of Red Iron Properties, LLC desires to close this site with a Notice of Residual
Petroleum (NORP). Per our earlier email conversations, during the week of January 4, 2020, Harmon
Environmental, PA will initiate a 1,000 foot radius receptor survey of this site.
Please call or email if you have any questions.
Richard Harmon, P.G.
Harmon Environmental, PA
615 Bruce Thomas Road
Monroe, NC 28112
704-292-4527
harmonenvironmental.com