MO-28635_47874_CA_UST-3_20210825_Notice of Intent UST Permanent Closure or Change-in-Service

UST-3 Notice of Intent: UST Permanent Closure or Change -in -Service
STATE USE ONLY
Return completed form to:
The DWM Regional Office located in the area where the facility is located. Also send a copy to the Central Office in Raleigh.
i D #
Date Received
SEE MAP ON THE BACK OF THIS FORM FOR THE CENTRAL AND REGIONAL OFFICE ADDRESSES.
INSTRUCTIONS (READ THIS FIRST)
Complete and return a UST-3 form at least thirty (30) days prior to closure or change -in-service activities.
Completed UST closure or change -in-service site assessment reports, along with a copy of the UST-2A and/or 2B forms, should be submitted
to the appropriate Division of Waste Management (DWM) Regional Office within thirty (30) days following closure activities. The UST-2 form
should also be submitted to the Central Office in Raleigh so that the status of the tanks may be changed to permanently closed and your
tank fee account can be closed out. Note: Tank fees may be due for unregistered tanks.
UST closure and change -in-service site assessments must be completed in accordance with the latest version of the Guidelines for Site
Checks, Tank Closure and Initial Response. The guidelines can be obtained at.https://deg.nc._qov/about/divisions/waste-management/ust.
Note: To close tanks in place you must obtain prior approval from the DWM Regional office located in the region where the facility is located.
You must make sure that USTs removed from your property are disposed of properly. When choosing a closure contractor, ask where the
tank(s) will be taken for disposal. Usually, USTs are cleaned and cut up for scrap metal. This is dangerous work and must be performed
by a qualified company. Tanks disposed of illegally in fields or other dumpsites can leak petroleum products and sludge into the environment.
If your tanks are disposed of improperly, you could be held responsible for the cleanup of any environmental damage that occu rs.
I. OWNERSHIP OF TANKS
II. LOCATION
Owner Name (Corporation, Individual, Public Agency, or Other Entity)
Gate North Carona, Inc.
FacilityName or Company
Gate #414
Street Address
Facility ID # (If known)
9617 Rocky River Road
00-0-000000036387
City County
Street Address
Charlotte Mecklenburg
3699 Concord Parkway
State Zip Code
City County Zip Code
NC 28215-8920
Concord Cabarrus 28027
Phone Number
Email
Phone Number
904-448-7035
MTalley@?qatepetro.com
704-784-4250
III. CONTACT PERSONNEL
Name:
CompanyName:
Job Title:
Phone Number:
Ken Czoer
Applied" Science and Engine rin, LLC
President
813-207-5657
IV. TANK REMOVAL, CLOSURE IN PLACE, CHANGE -IN SERVICE
1. Contact local fire marshal. 5. Provide a sketch locating piping, tanks and a P.E. or L.G., with all closure site assessment
2. Plan entire closure event. soil sampling locations. reports bearing the signature and seal of the
6 . Submit a closure report in the format of UST- P.E. or L.G. If a release has not occurred, the
3. Conduct Site Soil Assessment. supervision, signature or seal of a P.E. or L.G.
12 (including the form UST-2)fo within thirty
is not required.
4. If removing tanks or closing in place, refer to (30) days following the site investigation.
API Publication 2015 Cleaning Petroleum If a release from the tanks has occurred, the 8. Keep closure records for three (3) years.
Storage Tanks and 1604 Removal and site assessment portion of the tank closure
Disposal of Used Underground Petroleum
Storage Tanks. must be conducted under the supervision of
V. WORK TO BE PERFORMED BY
Contractor Name:
Contractor Company Name:
Rick Turner
JF Petroleum Group Company
Address:
State:
Zip Code:
Phone No:
6701 Northpark Boulevard, Suite B
NC
28216
704-393-8542
Prima Consultant Name:
Primary Consultant Company Name:
Consultant Phone No:
Scottlall
Geological Resources, Inc.
704-845-4010
VI. TANKS SCHEDULED FOR CLOSURE
OR CHANGE -IN-SERVICE
Proposed Activit
Closure
Change -In -Service
Removal
Abandonment in Place
New Contents Stored
Tank ID No.
Size In Gallons
Last Contents
1
20000
Gasoline
❑■
❑
2
12000
Gasoline
❑■
❑
3
10000
1 Diesel
❑■
❑
Li
Prior written approval to abandon a tank in place must be received from a DWM Regional Office.
VII. OWNER OR OWNER'S AUTHORIZED REPRESENTATIVE
Has a release from a UST system occurred at this location?❑ Yes ❑ No ❑ Unknown
I understand that I can be held responsible for environmental damage resulting from the improper disposal of my USTs.
Print name and official title: Tomie Benton, Vice President, Account Management
Signature
Date Signed
SCHEDULED REMOVAL DATE
Notify your DWM Regional Office
8/25/2021
9/22/2021
48 hours before this date if
scheduled removal date changes
UST-3 Rev 2/2021

Beverly, Trudy
From: Tomie Benton<[e-mail]>
Sent: Wednesday, August 25, 2021 3:19 PM
To: Beverly, Trudy
Cc: Scott Ball; [e-mail]
Subject: [External] Gate #414 Incident #47874
Attachments: 21-457; Gate #414; NCDEQ Proposal.pdf, UST-3 form signed.pdf, Gate 414 TA
20210825.xlsx
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 have attached the proposal, ePATA and UST-3 form for Gate #414, incident #47874. Please let us know if you need
anything more for this site.
Thanks,
r 3e4M01,1/
Vice President, Account Management
Geological Resources, Inc.
Celebrating 5o years of serving our clients
3502 Hayes Road I Monroe, NC 28110 1 website I facebook
704-845-4010-office 1252-367-2617-cell 1704-845-4012-fax