MO-88833_96073_CA_UST-62_20210318_24-Hour Notification of Discharge Form

UST-62
24-Hour Notification of Discharge Form
For Non -UST This form should be completed and submitted to the UST Section's regional office following a known or suspected release of
Releases of petroleum from a source other than an underground storage tank. This form is required to be submitted within 24 hours of
Petroleum in NC discovery of a known or suspected petroleum release
(DWM USE ONLY)
Suspected Contamination? (Y/N) Y
Release discovered
Incident # Priority Rank (H,I,L,U)
Confirmed GW Contamination? (Y/N) N
(time/date): 3/18/21 13:00
Received (time/date)
Confirmed Soil Contamination ?(Y/N) Y
Received by Region
Samples taken?(Y/N) _.NL Free product? (Y/N) N
Reported by (circle one): Phone, Fax or Report
If Yes(free product), state greatest thickness: feet
INCIDENT DESCRIPTION
Incident Name: Pepsi Harrisburg Facility
Address (street number/name): 22 Pepsi Way
County: Cabarrus
City/Town: Harrisburg Zip Code: 28075
Regional Office (circle one): Asheville Mooresville ayetteville,
Raleigh. Washington, Wilmington, Winston- a em
Latitude (decimal degrees): 35.31676 N Longitude (decimal degrees) : 80.66672 W Obtained by:
Describe suspected or confirmed release (nature of release, time/date of release, quantity of release, amount of free GPS
roduct: Fire pump filter allowed R]2roximatelv 35 to 40 galions of diesel fuel to be released and onto tit
ground adjacent to the building. Release was discovered today (3/18) at approx. l pm. ❑ Electronic topographic map
❑ GIS Address matching
Describe initial response/abatement (time/date release stopped, cleanup begun/completed, quantity of product ❑ Other
soil removed, confirmation sampling):
Pepsi, Haz-Mat, ATC, and Carolina Cat personnel responded and clean-up activities are being performed. ❑ Unknown
It is known
not at thi, time the amount of -oil to be removed.
Describe impacted receptors: Describe location:
None at this time
HOW RELEASE WAS DISCOVERED (Release Code)
(Check one)
Observation of Release at Occurrence ❑ Water Supply Well Contamination
❑ Visual or Olfactory Evidence ❑ Surface Water Contamination
❑ Soil Contamination ❑ Other (specify)
❑ Groundwater Contamination
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 petroleum product
source) cause) type released)
❑ AST (tank). Spill (Accidental) Petroleum Gasoline/ Diesel) ❑ DieselNeg. Oil
❑ AST Piping/ Dispenser ❑ Spill (Intentional) ❑ Both Petroleum Kerosene Blend
❑ AST Delivery Problem ❑ Corrosion & Nan -Petroleum ❑ E11 — E20 ❑ Vegetable Oil 100%
❑ OTR Vehicle Tank ❑ Physical or Mechanical ❑ E21 — E84 ❑ Heating Oil
❑ OTR Bulk Transport Tank Damage Location ❑ E85 — E99 ❑ Waste Oil
❑ RR Bulk Transport Tank ❑ Equipment Failure (Check one) ❑ Ethanol 100% ❑ Mineral Oil -no
❑ Transformer ❑ AST Overfill PCBs
Facility ❑ Mineral Oil -PCBs
❑ Unknown ❑AST Installation Problem
Residence
Other ❑ Unknown ❑ Other Petroleum
❑ Highway/Road
Products
❑ Other
Definitions presented on reverse Definitions presented on reverse Railway
❑
Other
Ownership
5. Federal 6. County 7. State
1. Municipal 2. Military 3. Unknown CED
Operation Type
1. Public Service 2. Agricultural 3. Residential 4. Education/Relig. 5. Industrial B. Commercia 7. Mining
Guidance presented on reverse
US I I-orm 52 (04/10) Page 1 of 2

IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected? 1. Yes 2. iV 3 Unknown Number of Water Supply Wells Affected
List of Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
1.
2.
3.
PARTY RESPONSIBLE FOR RELEASE
(if the source of the release is not an AST system or if it is an AST system and there is a responsible party other than the AST system owner/ operator)
Name of Person/Company
Pepsi Bottling Ventures/Bill Patterson (Dir. Safety and Health
Address
4141 ParkLane Avenue
City Raleigh
g
State NC Zip Code 27612
Telephone Number
[phone]
AST SYSTEM OWNER (if the source of the release is an AST system)
AST Owner/Company
Address
City
State
Zip Code Telephone Number
AST SYSTEM OPERATOR (if the source of the release is an AST system)
UST Operator/Company
Address
City State
Zip Code Telephone Number
LANDOWNER AT LOCATION OF INCIDENT
Landowner
Pepsi Bottling Ventures
Address
4141 ParkLane Avenue
City
Raleigh
State
NC
Zip Code Telephone Number
27612 (9l9) 865-7416
Draw Sketch of Area or Provide Map (showing incident site, location of release, two major road intersections, potential
receptors)
Attach sketch or map to form.
Give Directions to Incident Site Attach directions to form if necessary.
Site Map Attached - Take a right off Hwy 49 onto Pepsi Way. Continue to end of
road to the Pepsi facility.
Person Reporting Incident M. Jackson, PG Company ATC Associates of NC on behalf of PBV
Telephone Number [phone]
Title Senior Project Manager Address 609A Piner Rd, Suite 115 Wilmington, NC 28409
1 Date March 18, 2021
US I form U (04/10) Page 2 of 2
Definitions of Sources
AST (Tank): means the tank is used to store product
AST Piping: means the piping and connectors running from the tank to the dispenser or other end -use equipment
AST Dispenser: includes the dispenser and the equipment used to connect the dispenser to the piping
AST Delivery Problem: identifies releases that occurred during product delivery to the tank.
OTR Vehicle Tank: means the tank is used to store product to fuel an over the road vehicle
OTR Bulk Transport Tank: means a tank that is used to transport product in bulk over the road (by truck)
RR :bulk Transport Tank: means a tank that is used to transport product in bulk by train
Transformer: means electrical transformer
Other: serves as the option to use when the release source is known but does not fit into one of the preceding categories
Unknown: identifies releases for which the source has not been determined
Definitions of Causes
Spill (Accidental): use this cause when a spill occurs accidentally(e.g., when the delivery hose is disconnected from a fill pipe)
Spill (Intentional): use this cause when a spill occurs intentionally (e.g., intentional dumping or breakage)
Corrosion: use when a metal tank, piping, or other component has a release due to corrosion
Physical or Mechanical Damage: use for all types of physical or mechanical damage, except corrosion
Equipment failure: use when a release occurs due to equipment failure other than corrosion or physical or mechanical damage
AST 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)
AST Installation Problem: use when the problem is determined to have occurred specifically because the AST system was not installed properly
Other: use this option when the cause is known but does not fit into one of the preceding categories
Unknown: use when the cause has not been determined
Guidance: Ownership and Operator Type
Ownership select the category which describes owner of the AST system, bulk transport tank, or other release source
Operator Type select the category which describes the operation in which owner uses the AST system, bulk transport tank, or other release source

Beverly, Trudy
From: Beverly, Trudy
Sent: Monday, March 22, 2021 7:20 AM
To: Maureen Jackson
Subject: RE: [External] Pepsi Harrisburg UST-62
Hey Maureen,
Ron forwarded this one to me. I am the UST Corrective Action Project Manager for Cabarrus County. Please send future
communications related to this release to me.
Thanks and have a great day,
Trudy
E Q
D
N varlmen[al t�na'on ment7l 4uaY1!�
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.Beverlykncdenr. 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: hops://deq.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-prosram
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):
hi�2s://deg.nc.gov/about/divisions/waste-management/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
https://files.nc.aov/ncdep/Waste%2OManaeement/DWM/UST/WhatsNew/Final-Electronic-Document-Submittal-Policv.adf
htips://files.nc.,gov/ncdegiWaste%2OManagement/DWM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx
From: Taraban, Ron
Sent: Monday, March 22, 2021 6:48 AM
To: Beverly, Trudy <[e-mail]>
Subject: FW: [External] Pepsi Harrisburg UST-62
From: Maureen Jackson <[e-mail]>
Sent: Friday, March 19, 2021 10:53 AM
To: Taraban, Ron <[e-mail]>
Cc: Gabe Araos <[e-mail]>; Peterson, Bill <[e-mail]>
Subject: [External] Pepsi Harrisburg UST-62
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Good morning. A UST-62 is attached

Thank you
Maureen
Maureen Jackson I SENIOR PROJECT MANAGER I ATC Group Services LLC
Direct [phone]
ATC
609A Piner Road Suite 115 1 Wilmington, NC 28409
[e-mail] I www.atcaroupservices.com
This email and its attachments may contain confidential and/or privileged information for the sole use of the intended recipient(s). If you are
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