MO-28635_47874_CA_UST-61_20180427_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? (YIN) Y
Facility ID Number 00-0�-00 of?
Incident# Risk (H,I,L,U)
Confirmed GW Contamination? (YIN)
Date Leak Discovered Y
Received On Received By
Reported by (circle one): Phone, Fax or Report
Confirmed Soil Contamin tion ?(Y/N)
Samples Taken?(Y/N) =
Comm/Non-Commercial? MAa
Reg/Non-regulated? AK.—
Region
Free Product? (YIN) IM If Yes, State Greatest
Thickness
INCIDENT DESCRIPTION
Incident Name: GA11C Ll )11
Address: e (0�9 cwcou #0014W.4y 5o
County: f
Regional Office (circle one): Asheville, Mooresville, Fayetteville,
City/rown: � ew
2
Zip Code: 2 00 2 T I
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (dedmai d.ere.a): 3 5% a 3'V&To Longitude (decimal degme.) : 430,(p (aL.($LZ(p
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
Q1 Topographic map
El GIS Address matching
❑ Other
❑ Unknown
Describe location:
C0r77/Imrv9>e0 SOIL 4ciW &ZIA16 ,OrAmSd[ :5 t r,P R
/MOWi 0 DlScti�GY t� 4 /L
A,O �c P/40� P e5 Sou. AlMir
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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) Sq
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 F+ Gasoline/ Diesel/ ❑ DieselNeg. Oil
Kerosene Blend
❑ Piping ❑ Overfill ❑ Non -Petroleum ❑ Heating Oil ❑ Vegetable Oil 100%
❑ Dispenser ❑ Corrosion ❑ Both ❑ Other Petroleum ❑ E10—E20
❑ Submersible Turbine Pump ❑ Physical or Mechanical Products
❑ ❑ E21—E84
Damage Location Metals
❑ Delivery Problem ❑ Install Problem (Check one) ❑ Other Inorganics ❑ E85—E99
Other ❑ Other Organics ❑ Ethanol 100%
❑ Other Facility
❑ Unknown
❑ Residence ❑ E01 —E09
Unknown
Definitions resented on reverse eflnit/ons resented on reverse I ❑ Other
Ownership
1. Municipal 2. Military 3. Unknc6n 4. PrivaW 5. Federal 6. County 7. State
Operation Type
1. Public Service 2. Agricultural 3. Residential 4. Education/Relig. 5. Industrial 6. Commercia 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: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
1.
2.
3.
UST SYSTEM OWNER
UST Owner/Company
Gih'C � UGeZGm 'Gowp,9,a
Point of Contact
Y►Ae eic-
Address
po6ox 23roZ�
City Ja� �✓
SlateFt
Zip3dzeKl
eNum
Telephone 3�'-
R� 72Zo
UST SYSTEM OPERATOR
UST Operator/Company �
G�PtvvtFz Nv449n
Address
Pa &)e 23c�Z
City
State
Zip C e Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
IVI"O A PB aves co 10. o 0
Address
P. 0 fax 3�Z
city
sawutcc�
State
?'L
Zip Code
3 22v 1
Telephone Number
OLl �3 -zzh
Draw Sketch of Area (showing two major road intersections) or Attach Map
Person Reporting Incident
Company (�gp I.661 Ok NC
ITelephone Number
WIVIO
Title
Address .L &� — Ls 6./id
1Date
UST Form 61 (02/08)
Page z or 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

Beverly, Trudy
From: Beverly, Trudy
Sent: Tuesday, July 13, 2021 10:38 AM
To: Scott Ball
Cc: Tomie Benton
Subject: RE: [External] Gate #414, Concord, Cabarrus Co., NC
Great. Thank you.
Trudy
From: Scott Ball[mailto:[e-mail]]
Sent: Tuesday, July 13, 2021 10:09 AM
To: Beverly, Trudy <[e-mail]>
Cc: Tomie Benton<[e-mail]>
Subject: RE: [External] Gate #414, Concord, Cabarrus Co., NC
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Trudy
Yes, I have that. See below.
Company:
Gate Petroleum Company
Name:
Marlene Talley
Title:
Address:
PO Box 23627 Map
Jacksonville, FL 32241
Phone:
904.448.2998
Phone 2:
Fax:
904.448.3028
Email:
[e-mail]
Thanks
Scott Ball
Project Manager
Geological Resources, Inc.
3502 Hayes Road
Monroe, NC 28110
Main [phone] Fax [phone]
carriekennedv(@L-eoloeicalresourcesinc.com
www.geologicalresourcesinc.com
NCPCM Vendor of the Year Recipient
i

From: Beverly, Trudy <[e-mail]>
Sent: Tuesday, July 13, 2021 10:02 AM
To: Scott Ball <[e-mail]>
Cc: Tomie Benton<[e-mail]>
Subject: RE: [External] Gate #414, Concord, Cabarrus Co., NC
Hey Scott,
Do you have an email address for the Gate Petroleum contact (Marlene Talley) for the NORR?
Thanks,
Trudy
cc���DE <A
QW;
fH i:ak ,
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.13everlykncdenn 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:Hdeg.nc.gov/about/divisions/waste-management/ust/ast-program
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):
htt2s://deg.nc.gov/about/divisions/waste-management/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
htti)s:Hfiles.nc.eov/nedea/Waste%2OManauement/DWM/UST/W hatsNew/Final-Electronic-Document-Submittal-Policv.l)df
https:Hfiles.nc. gov/ncdeq[Waste%2OManagement/D WMiUST/Corrective%2OAction/UST%2Ofile%20names%20for%2OLaserfiche.docx
From: Scott Ball [mailto:[e-mail]]
Sent: Thursday, July 8, 2021 12:42 PM
To: Beverly, Trudy <[e-mail]>
Cc: Tomie Benton<[e-mail]>
Subject: RE: [External] Gate #414, Concord, Cabarrus Co., NC
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
No Problem.
Thanks again!
Scott Ball
Project Manager
Geological Resources, Inc.
3502 Hayes Road
Monroe, NC 28110
Main [phone] Fax [phone]

[e-mail]
www.geologicalresourcesinc.com
NCPCM Vendor of the Year Recipient
From: Beverly, Trudy <[e-mail]>
Sent: Thursday, July 8, 2021 12:41 PM
To: Scott Ball <[e-mail]>
Cc: Tomie Benton<[e-mail]>
Subject: RE: [External] Gate #414, Concord, Cabarrus Co., NC
I appreciate you reaching out and sending the info.
Have a great day,
Trudy
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
North Carolina Department of Environmental Quality
'��U UST Section, Mooresville Regional Office
704.235.2182 (Office)
Trudy.13everlykncdenn 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-manaaement/ust
Branch's Above Ground Storage Tanks Website Address: ht!ps:Hdeg.nc.gov/about/divisions/waste-management/ust/ast-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httos://dea.nc. gov/about/divisions/waste-management/waste-management-rules-data/waste-management-gis-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://deq.ne.gov/about/divisions/waste-manalzement/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
httys://files.nc.tiov/nedea/Waste%2OManauement/DWM/UST[W hatsNew/Final-Electronic-Document-Submittal-Policv.udf
htips:Hfiles.nc. gov/ncdeq/Waste%2OManagement/D WNI/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx
From: Scott Ball [mailto:[e-mail]]
Sent: Thursday, July 8, 2021 12:23 PM
To: Beverly, Trudy <[e-mail]>
Cc: Tomie Benton<[e-mail]>
Subject: RE: [External] Gate #414, Concord, Cabarrus Co., NC
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Hi Trudy
Please see attached Soil Assessment/Site Check report from 4-2018. Outside of the UST-61 form, this is all we have to
send to you.
Thanks!

Scott Ball
Project Manager
Geological Resources, Inc.
3502 Hayes Road
Monroe, NC 28110
Main [phone] Fax [phone]
[e-mail]
www.geologicalresourcesinc.com
NCPCM Vendor of the Year Recipient
From: Beverly, Trudy <[e-mail]>
Sent: Thursday, July 8, 2021 12:13 PM
To: Scott Ball <[e-mail]>
Cc: Tomie Benton<[e-mail]>
Subject: RE: [External] Gate #414, Concord, Cabarrus Co., NC
Hey Scott,
The date on UST-61 form is one month prior to me transferring to the UST section. Brett Morris vacated the position a
few months before I started. If the form was emailed to Brett, no one would have received it. Email me any additional
information that you have about the site (other than the UST-61). I'll try to get it reviewed and respond back by the end
of Tuesday next week.
Trudy
Trudy Beverly, L.G.
D, E Qq ; 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: ht_pt s:Hdeq.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: ht!ps:Hdeg.nc.aov/about/divisions/waste-management/ust/ast-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httns://dea.ne. 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):
httDs: //dea.nc. giov/about/divisions/waste-mana2ement/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
htti)s:Hfiles.ne.izov/ncdea/Waste%2OMana2ement/DWM/UST/W hatsNew/Final-Electronic-Document-Submittal-Policy.pdf
https:Hfiles.nc.gov/ncdeq/Waste%20Management/D WM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx
From: Scott Ball [mailto:[e-mail]]
Sent: Thursday, July 8, 2021 11:29 AM
To: Beverly, Trudy <[e-mail]>
Cc: Tomie Benton<[e-mail]>
Subject: [External] Gate #414, Concord, Cabarrus Co., NC

CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Hi Trudy
I am contacting you concerning the Gate Petroleum #414 site located at 3699 Concord Parkway South in Concord,
Cabarrus County.
We conducted some soil sampling during a dispenser sump replacement at this site in April 2018. Soil contamination
was confirmed. We submitted a UST-61 form (see attached) to the NCDEQ-MRO on 4/27/18. To date we have not
received any response/NORR from the NCDEQ concerning this incident.
Gate Petroleum has decided to remove the UST system from the site in November of 2021.
Can you assign an incident number for this release? Once received, I will submit to you a UST-3 form detailing the
schedule for closure/removal of the UST system.
Please contact me with any questions. I am best reached by mobile phone at 704-451-2408.
Thankyou
Scott Ball
Project Manager
Geological Resources, Inc.
3502 Hayes Road
Monroe, NC 28110
Main [phone] Fax [phone]
[e-mail]
www.geologicalresourcesinc.com
NCPCM Vendor of the Year Recipient