MO-28475_47727_CA_UST-61_20210224_24‐Hr Release and UST Leak Reporting Form

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 primary source)
(Check primary cause) (Check one) (Check primary product type released)
❑ Tank
❑ Spill ❑ Petroleum ❑ Gasoline/ Diesel/ ❑ Diesel/Veg. Oil
❑ Piping
❑ Overfill ❑ Non -Petroleum Kerosene Blend
❑ Dispenser
❑Heating Oil ❑ Vegetable Oil 100%
Corrosion Both
❑❑
❑ Other Petroleum ❑ E10 - E20
❑ Submersible Turbine Pump
❑Physical/Mechanical
❑ Delivery Problem
Location Products
Damage ❑ E21 - E84
(Check one) Metals
❑
❑ Install Problem ❑ E85 - E99
❑ Spill Bucket
❑ Other Inorganics
❑ Other [-]Facility ❑Ethanol 100%
❑ Other
❑ Other Organics
❑ Unknown ❑Residence ❑ 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 7. Mining
UST Form 61 (02/19) Page 1 of 2

Water Supply Wells Affected? 1. Yes
Number of Water Supply Wells Affected
IMPACT ON DRINKING WATER SUPPLIES
2. No 3. Unknown
Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
1.
2.
3.
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 (02/19)
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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Figure 1
r ;;: Site Location
Bethpage Grocery
_ f T 4940 Mooresville Road
Kannapolis, North Carolina
Cabarrus County
o 500 M Incident No. N/A
C 2000 FT GRI Project No. 5567
Date: 02/07/2021 Location: 35.488624° N-80.661416° W

LEGEND
TREE LINE
----UNDERGROUND STORAGE TANK
Q FUEL DISPENSER
Note:
1. This Site Map Is based on data from the Cabarrus County, NC GIS
office.
2. This site was not professionally surveyed; locations of utilities, tank
components and other site features are approximate.
7
ec
0 20 40 80 - J,J.Lt�(OrHr
Bethpage Grocery 4940 Mooresville Road
Incident No. N/A Kannapolis, North Carolina
( IN. FEET ) GRI Project No. 5T Caborrus County
Geological Resources, Inc. 1 inch =40 ft Date: 02/07/2021. Drawn by. DTH I Figure:
IN

igwrbon
Analysis Results
CDCD
Client: GRI
Samples taken
Tuesday, February 9, 2021
Q E d LA Bry
Address:
a µa,o cruv,no,ux+�rurww o,nGr+O StCi
Samples extracted
Tuesday, February 9, 2021
Samples analysed
Tuesday, February 9, 2021
Contact: MATT SMITH
Operator
MAX MOYER
Project: BETH PAGE GROCERY
T03308
Matrix
Sample ID
Dilution
BTEX
GRO
DRO
TPH
Total
16 EPA
BaP
% Ratios
HC Fingerprint Match
used
Aromatics
PAHs
C5:10
C1108.0
C18+
C6-C9
C5-C10
C10-C35
C5-C35
C10-C35
Soil
JOB - 1
9.0
<0.22
<0.22
1.2
1.2
0.5
0.027
<0.003
0
94
6
Deg.Fuel 84.2%,(FCM),(TD)
Soil
OB - 2
9.0
<0.22
<0.22
1
1
0.4
0.016
<0.003
0
93.9
6.1
V.Deg.Light Fuel 84.9%,(FCM),(TD)
Soil
OB - 3
9.0
<0.22
<0.22
0.5
0.5
0.27
0.013
<0.003
0
79
21
V.Deg.PHC 86.5%,(FCM),(TD)
Soil
UST - 1 - 14'
13.0
<0.3
<0.3
3.7
3.7
2.5
0.13
0.001
0
92.4
7.6
Deg.Light Fuel 80.3%,(FCM),(BO),(TD)
Soil
UST - 2 - 14'
12.0
<0.3
<0.3
0.09
0.09
0.04
0.002
<0.004
0
81.1
18.9
Residual HC,(TD)
Soil
UST - 3 - 14'
12.0
<0.3
<0.3
<0.12
0.017
0.017
0.001
<0.004
0
34
66
Residual HC,(TD)
Soil
UST - 4 - 14'
6.0
<0.15
<0.15
<0.06
0.01
0.01
<0.001
<0.002
0
100
0
Residual HC,(TD)
Soil
PL - 1
11.0
<0.27
<0.27
<0.11
<0.27
<0.006
<0.006
<0.003
Q
0
Q
PHC ND,(FCM),(TD)
Soil
PL - 2
9.0
<0.22
<0.22
<0.09
0.008
0.008
<0.001
<0.003
0
100
0
Residual HC,(TD)
Soil PL - 3
<0.27
<0.27
<0.11 <0.27
<0.006
<0.006
<0.003 0 100
0 Residual HC,(TD)
QC ch
iir
87.2%
Concentration values in mg/kg for soil samples and mg/L for water samples. Soil values uncorrected for moisture or stone content. Fingerprints provide a tentative hydrocarbon identification.
Abbreviations :- FCM = Results calculated using Fundamental
Calibration Mode:
% = confidence of hydrocarbon identification : (PFM) = Poor Fingerprint
Match : (T) = Turbid : (P) = Particulate detected
B = Blank Drift: (SBS)/(LBS) = Site Specific or Library Background Subtraction
applied to result: (BO) = Background Organics detected : (OCR)
= Outside cal range : (M) = Modifed Result.
% Ratios estimated aromatic carbon number proportions : HC = Hydrocarbon :
PHC = Petroleum HC : FP = Fingerprint only. Data generated by HC-1 Analyser

CDCD
Client: GRI
Samples taken
Tuesday, February 9, 2021
Q E d LA Bry
Address:
a pa,o cruv,no,utnirurww o,nGr+O StCi
Samples extracted
Tuesday, February 9, 2021
Samples analysed
Tuesday, February 9, 2021
Contact: MATT SMITH
Operator
MAX MOYER
Project: BETH PAGE GROCERY
3308
Matrix
Sample ID
Dilution
BTEX
GRO
DRO
TPH
Total
16 EPA
BaP
% Ratios
used
Aromatics
PAHs
4
C6-C9
C5-C10
C10-C35
C5-C35
C10-C35
C5:10
C 108.0
C18+
Soil
DI - 1
448.0
1934
8594
233.6
8827.6
201.5
7.8
<0.009
96.6
3.4
O
Undeg.Gas 85.5%,(FCM)
Soil
DI-2
20.0
<0.5
<0.5
<0.2
0.014
0.014
0.002
<0.006
0
0
100
Residual HC
Soil
PL - 4
17.0
<0.4
<0.4
0.7
0.7
0.06
0.004
<0.005
0
84.9
15.1
Deg Fuel 56.8%,(FCM)
Soil
PL - 5
25.0
<0.6
<0.6
<0.25
<0.6
<0.013
<0.013
<0.008
0
0
0
PHC ND,(FCM)
Soil
PL - 6
19.0
<0.4
<0.4
0.8
0.8
0.09
0.007
<0.006
0
89.8
10.2
Deg Fuel 71.8%,(FCM)
Soil
PL - 7
21.0
<0.5
<0.5
<0.21
0.018
0.018
0.002
<0.006
0
34
66
PHC ND,(FCM)
Soil
PL - 8
23.0
<0.5
<0.5
<0.23
<0.5
<0.012
<0.012
<0.007
0
0
O
PHC ND,(FCM)
Soil
PL - 9
21.0
<0.5
<0.5
0.3
0.3
0.27
0.028
<0.006
0
92.4
7.6
Residual PHC
Soil
PL - 10
19.0
<0.4
<0.4
0.13
0.13
0.1
0.011
<0.006
0
100
0
Residual HC
Soil 0 - 1 - B
5
58.3
24.5 82.8 3.3
0.13
<0.007 95.5 4.4
0.1 Deg Gas 61.4%,(FCM),(TD)
QC cl
kr
FC
Concentration values in mg/kg for soil samples and mg/L for water samples. Soil values uncorrected for moisture or stone content. Fingerprints provide a tentative hydrocarbon identification.
Abbreviations :- FCM = Results calculated using Fundamental
Calibration Mode:
% = confidence of hydrocarbon identification : (PFM) = Poor Fingerprint
Match : (T) = Turbid : (P) = Particulate detected
B = Blank Drift: (SBS)/(LBS) = Site Specific or Library Background Subtraction
applied to result:
(BO) = Background Organics detected : (OCR)
= Outside cal range : (M) = Modifed Result.
% Ratios estimated aromatic carbon number proportions : HC = Hydrocarbon :
PHC = Petroleum HC : FP = Fingerprint only. Data generated by HC-1 Analyser

i9wrbon Analysis Results
CDCD
Client: GRI
Address:
Contact: MATT SMITH
Project: BETH PAGE GROCERY
Samples taken
Q E d LA Bry Samples extracted
a pa,o cruv,no,utnirurww o,nGr+O StCi
Samples analysed
Operator
Tuesday, February 9, 2021
Tuesday, February 9, 2021
Tuesday, February 9, 2021
MAX MOYER
T03308
Matrix
Sample ID
44
Dilution
used
BTEX
C6-C9
GRO
C5-C10
DRO
C10-C35
TPH
C5-C35
Total
Aromatics
C10-C35
16 EPA
PAHs
BaP
% Ratios
HC Fingerprint Match
I C5:10
C 108.0
C18+
Soil
TL - 1
264.0
709
4662
141.5
4803.5
117.8
4.6
<0.07
96.4
3.6
0
Undeg.Gas 79.8%,(FCM)
Soil
0-1 - B2
19.0
<0.9
4.5
4.3
8.8
0.4
0.019
<0.006
91.8
8.2
0
50%,(FCM)
Soil
TL - 2
346.0
564
2675
1350
4025
131.7
5.1
<0.10
96.1
3.9
0
Deg.Gas 69%,(FCM)
or nc chec 101.1 %
Concentration values in mg/kg for soil samples and mg/L for water samples. Soil values uncorrected for moisture or stone content. Fingerprints provide a tentative hydrocarbon identification.
Abbreviations :- FCM = Results calculated using Fundamental Calibration Mode: % = confidence of hydrocarbon identification : (PFM) = Poor Fingerprint Match : (T) = Turbid : (P) = Particulate detected
B = Blank Drift: (SBS)/(LBS) = Site Specific or Library Background Subtraction applied to result: (BO) = Background Organics detected : (OCR) = Outside cal range : (M) = Modifed Result.
% Ratios estimated aromatic carbon number proportions : HC = Hydrocarbon : PHC = Petroleum HC : FP = Fingerprint only. Data generated by HC-1 Analyser

i9wrbon Analysis Results
CDCD
Client: GRI
Address:
Contact: MATT SMITH
Project: BETH PAGE GROCERY
Q E d LA Bry
a pa,o cruv,no,utnirurww o,nGr+O StCi
Samples taken
Samples extracted
Samples analysed
Operator
Tuesday, February 9, 2021
Tuesday, February 9, 2021
Tuesday, February 9, 2021
MAX MOYER
T03308
Matrix
Sample ID
Dilution
used
BTEX
C6-C9
GRO
C5-C10
DRO
C10-C35
TPH
C5-C35
Total
Aromatics
C10-C35
16 EPA
PAHs
BaP
% Ratios
HC Fingerprint Match
C5:10
C1108.0
C18+
Soil
ITL - 3
588.0
362
2467
82.9
2549.9
68.8
2.6
<0.17
96
4
0
Undeg.Gas 81.1 %,(FCM)
Soil
TL - 4
775.0
226.6
1359
922
2281
84.7
3.3
<0.002
95.1
4.9
0
Deg.Gas 75.6%,(FCM)
Soil
TL - 5
410.0
239.4
4062
160.7
4222.7
127.1
5
<0.12
95.5
4.4
0
Deg Gas 77.3%,(FCM)
or nc chec
Concentration values in mg/kg for soil samples and mg/L for water samples. Soil values uncorrected for moisture or stone content. Fingerprints provide a tentative hydrocarbon identification.
Abbreviations :- FCM = Results calculated using Fundamental Calibration Mode: % = confidence of hydrocarbon identification : (PFM) = Poor Fingerprint Match : (T) = Turbid : (P) = Particulate detected
B = Blank Drift: (SBS)/(LBS) = Site Specific or Library Background Subtraction applied to result: (BO) = Background Organics detected : (OCR) = Outside cal range : (M) = Modifed Result.
% Ratios estimated aromatic carbon number proportions : HC = Hydrocarbon : PHC = Petroleum HC : FP = Fingerprint only. Data generated by HC-1 Analyser

Beverly, Trudy
From: Beverly, Trudy
Sent: Wednesday, February 24, 2021 1:09 PM
To: Matt Smith
Subject: RE: [External] Bethpage Grocery - UST-61 Form
Received.
Trudy
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
D— I E North Carolina Department of Environmental Quality
LMpjrL��[0 � � �r 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://deg.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: hgps://deg.nc.gov/about/divisions/waste-management/ust/ast-proeram
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httos://dea.nc. eov/about/divisions/waste-manaeement/waste-manaeement-rules-data/waste-manaeement-eis-mans
File Review Procedures:
ht!ps:Hdeq.nc. gov/about/divisions/waste-manaeement/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
httns://dea.nc. eov/about/divisions/waste-manaeement/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
httys://files.ne.tiov/nedea/Waste%2OManaeement/DWM/UST[W hatsNew/Final-Electronic-Document-Submittal-Policv.udf
httys://files.nc. gov/ncdeq/Waste%20Management/D WMJUST/Corrective%2OAction/UST%2Ofile%20names%20for%2OLaserfiche.docx
From: Matt Smith [mailto:[e-mail]]
Sent: Wednesday, February 24, 2021 1:04 PM
To: Beverly, Trudy <[e-mail]>
Subject: [External] Bethpage Grocery - UST-61 Form
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Good Afternoon Trudy,
Please find attached the UST-61 form for Bethpage Grocery Facility ID #00-0-0000004437. Let me know if you have any
questions.
Thanks,
Matthew T. Smith
Junior Project Manager
Geological Resources, Inc.
3502 Hayes Road

Monroe, NC 28110
Main [phone] Cell [phone]
Fax [phone]
[e-mail]
www.geologicalresourcesinc.com