MO-28338_47594_CA_UST-61_20200916_24-Hour Release and UST Leak Reporting Form

UST0161
24-Hour Releasie Iand ]UST L601k 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? (YfN) Y
Facility ID Number _
Incident # Risk (H,I,L,U)
Confirmed GW Contamination? (Y1N)
Date Leak Discovered
Received On Received By
Confirmed Soil Contamination ?(YIN)
CommtNon-Commercial?
Reported by (circle one): Phone, Fax or Report
Samples Taken?(YIN) Y
Reg/Non-regulated?
Region
Free Product? (YIN) N If Yes, State Greatest
Thickness N/A
INCIDENT DESCRIPTION
Incident Name &j Union Street S, Concord, NC
Address: 61 Vnion Street S
County Cabarrus
Regional Office (circle one): Asheville, Mooresville, Fayetteville
City/Town Concord Zip Code. 28025
Raleigh, Washington. Wilmington, Winston-Salem
Latitude (decamaidegrees): 35'24'35.62"N Longitude (deomaldegrees) 80°34'46-32"W
Obtained by:
QGPS
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
On September 14, during excavation for sewer lines. a UST was encountered. On September 15, the UST was
excavated along with the contaminated soils. The soil contamination could not be successfully excavated from
the site due to property boundaries, utilities and existing buildings.
❑Unknown
Describe location:
SEP 21 2020
HOW RELEASE WAS
dJST
YYA
(Ch 1
❑Release Detection Equipment or Methods [�]Visual/Odor ❑Groundwater Contamination
QDuring 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 E Petroleum ❑ Gasoline/ Diesel/ ❑ Diesel/Veg. Oil
❑ Piping ❑ Overfill ❑ Non -Petroleum Kerosene Blend
❑ Dispenser Q Corrosion ❑ Both F Heating Oil ❑ Vegetable Oil 100%
❑ Submersible Turbine Pump ❑ Physicaumechanical ❑ Other Petroleum ❑ E10 - E20
Products
Location
❑ E21 - E84
❑ Delivery Problem Damage (Check one) El Metals
Install Problem ❑ E85 - E99
❑ Spill Bucket
Other Facility ❑ ❑
❑ ❑ Other Inorganics Ethanol 100%
❑ Other ❑ ❑ Other Organics ❑ Unknown ❑Residence E01 - E09
❑ Unknown
QOther
Definitions presented on reverse
Definitions presented on reverse
Ownership
1. Municipal 2, Military 3. Unknown 4. Private 5. Federal 6. County 7. State
Aeration Type
Public Service 2. Agricultural 3. Residential 4. EducationlRelig 5 Industrial 6. Commercial 7 Mining
UST Fort 61 (02119) rage i Or t

IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected? I Yes 2 No 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 ACiZlAui -�v, CCI'ACA,,�i
Point of Contact 1 Address
City State Zip "ode
�elepho`neNur Number
UST SYSTEM OPERATOR
LIST CiperatorrCompany
Address
NIA
N/A
City
State
Zip Code
Telephone Number
N/A
N/A
NIA
N/A
LANDOWNER AT LOCATION OF LIST INCIDENT
Landowner
Address
CAiAgev�, (Q-ITL � "' I
PC) 70 -7
City
State
Zip Code
Telephone Number
CONE 0 9 0
1 JU C
I 76,fl-3c,5-coAs
Draw Sketch of Area (showing two major road intersections) or Attach Map
Person Reporting Incident Ky, i g ItOfA
rro -s Company L,
64 biet (
Telephone Number -1-4-5,R7,)S
cS
Title AGeA No Cftcg ietaw y
Address 'PC, 1&-t, 7 0 -1 (CwLuQ, i), (1P
I
Date
I q-)G-ae, I
UST Form 61 (02/19)
rage z OT z
Definitions of Sources
Tank means the tank that stores the product and is part of the underground storage rank system
Piping means the piping and connectors running from the tank or submersible turbine prionp to the dispenser or other end -use equipment tVent, vapor recovery, or fill
lines are excluded )
Dispenser include,, the dispenser and the equipment used to connect the dispenser to the piping; e _a release from a suction pump or from wnmonenri 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 identities releases that occurred during product delivery to the tank Jvmcal causes associated with this source are spills and overfills
Others serves as the option to use when the release source is known but does not fit into one of the preceding categories (eg , for releases from vent lines, vapor
recovery lines. and fill lines)
L,nknown identities releases for which the iciur" has not been deterin med
Definitions of Causes
Spill use this cause when a spill occurs (e -,. when the deliver-, hose is disconnected from the tank fill pipe or when the nozzle is removed from the dispenser)
Overfill use when an overfill occurs ie,g- overfills may occur from the fill pipe at the tank or when the nuzzle fails to shut offat 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 ot'rust)
Installation problem use when the problem is determined to have occurred specifically because the I-I'STsy stern \vas not installed properly
Other use this option when the cause is lonrvan but does not fit into one of the preceding categories (e g, putting regulated substances into monitoring wells)
t,nknovvn use when the cause has not been determined

r
RECsIVED
SEP 21 Zo2o

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)
Release discovered
Incident # Priority Rank (H,I,L,U)
Confirmed GW Contamination? (Y/N)
(time/date):
Received (time/date)
Confirmed Soil Contamination ?(Y/N) _
Received by Region
Samples taken?(Y/N) Free product? (Y/N)
Reported by (circle one): Phone, Fax or Report
If Yes(free product), state greatest thickness: feet
INCIDENT DESCRIPTION
Incident Name: 61 Union St S, Concord, NC
Address (street number/name): 61 Union St
County: Cabarrus
City/Town: Concord
Zip Code: 28205
Regional Office (circle one): Asheville, Mooresville, Fayetteville,
Raleigh, Washington, Wilmin on, Winston-Salem
Latitude (decimal degrees): 35°24'35.62"N Longitude (decimal degrees) : 80°34'46.32"W
Obtained by:
0 GPS
Describe suspected or confirmed release (nature of release, time/date of release, quantity of release, amount of free
product):
❑ Electronic topographic map
❑ GIS Address matching
On November 12, 2020, while installed drilled piers, the contractor encountered contaminated groundwater with a
petroleum odor.
❑ Other
Describe initial response/abatement (time/date release stopped, cleanup begun/completed, quantity of product
soil removed, confirmation sampling):
❑ Unknown
Describe location:
The contaminated soils were stockpiled on site.
Describe impacted receptors:
Unknown at this time
HOW RELEASE WAS DISCOVERED (Release Code)
(Check one)
❑ Observation of Release at Occurrence ❑ Water Supply Well Contamination
0 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) 0 Petroleum ❑ Gasoline/ Diesel/ ❑ Diesel/Veg. Oil
❑ AST Piping/ Dispenser ❑ Spill (Intentional) ❑ Both Petroleum Kerosene Blend
❑ AST Delivery Problem ❑ Corrosion & Non -Petroleum ❑ Ell — E20 ❑ Vegetable Oil 100%
❑ OTR Vehicle Tank ❑ Physical or Mechanical ❑ E21 — E84 0 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
0 Unknown ❑AST Installation Problem
❑Residence
❑ Other ❑ Unknown ❑ Other Petroleum
❑ Highway/Road
Products
❑ Other
❑ Railway
Definitions presented on reverse Definitions presented on reverse
❑ Other
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 Guidance presented on reverse
UST Form 62 (04/10) Page 1 of 2

IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected? 1. Yes2. No 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
Address
City
State
Zip Code
Telephone Number
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 Cabarrus County
Address PO Box 707
City Concord
State NC
Zip Code 28026
Telephone Number
704-305-9723
Draw Sketch of Area or Provide Map (showing incidentslte, 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.
See attached map
Person Reporting Incident Michael Zavislak
Company SUMMIT
Telephone Number 704-504-1717
Title envr Dept Manager
Address 3575 Centre Circle, Fort Mill, SC 29715
Date 11/20/2020
UST Form 62 (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

r
Contaminated
Groundwater
EV / ",:,w
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U
PI
Figure 4
Aerial Photograph
61 Union St. South SUMMIT ELT, PC
Project:4314.E0006
Concord, NC SUMMIT
1
DA!MichaelNSUMMIT! \4314 - Trifecta Services Company\4314.E0006 - 77 Union St. S Concord NC\Contaminated Soils\R-Ph I - Figure 4 Aerial.doc

Beverly, Trudy
From: Michael Zavislak <[e-mail]>
Sent: Friday, December 11, 2020 12:37 PM
To: Beverly, Trudy
Subject: [External] Cabarrus County
Attachments: UST-62 11-20-2020.pdf
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Trudy,
I'm following up on this to see what the next step is.
The contractor and county decided not to excavate to the groundwater as to not generate contaminated soils. Do I
need to complete an Initial Abatement Action Report? the contractor and county also would like to know what the
possible next steps are for groundwater monitoring.
Thanks
Michael
/A&
SUMMIT
Michael D. Zavislak, NRCC-EAC, CHMM, CIH, PE
Environmental Department Manager
[e-mail]
Charlotte Office • 3575 Centre Circle Drive • Fort Mill, SC 29715
704.504.1717 Office • 704.504.1125 Fax • 803.238.1080 Cell
www.summit-companies.com
Charlotte -HQ • Raleigh • Columbia • Greenville • Charleston
qSCE
Aff k4aon Society of CMY +ter
2017-2020 South Carolina Section Director -At -Large