MO-28991_48185_CA_UST-61_20210617_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
in NC
known or suspected release
(DWM USE ONLY)
Suspected Contamination? (Y/N) Yes
Facility ID # 00-036129
Y
Incident # Risk (H,I,L,U)
Received On Received By
Confirmed GW Contamination? (Y/N
Confirmed Soil Contamination? (YEN) YP.S
Date Leak Discovered 2/4/21
Region
Samples Taken? (Y/N) es
on-Commercial?
Reported by (circle one): Phone, Email or Report
NAPL? (Y/N) O
If Yes, State Greatest Thickness
Won-regulated?
INCIDENT DESCRIPTION
Incident Name: Circle K Store 2723470
Address: 3065 Dale Earnhardt Blvd
County: Cabarrus
City/Town: Concord
Zip Code: 2$0$3
Regional Office (circle one): Asheville, Fayettevill Mooresville,
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): 35.4732 N
Longitude (decimal degrees):-80.6045 W
Location 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 NAPL present and recovery efforts, initial responses conducted, impacts to receptors)
❑ Topographic map
During UST closure activities, soil contamination confirmed associated with
❑ GIS Address matching
fuel dispensers 9&10, on the north-northwest most extent of the dispenser
Other
Google Earth
dispenser and product line removal. TPH-DRO detected at 342 mg/kg.
❑ Unknown
Describe location:
Amount released is unknown.
LNAPL not observed during excavation. Impact to receptors not likely.
HOW RELEASE WAS DISCOVERED (Release Code)
(Check one)
❑ Release Detection Equipment or Methods ❑ Visual/Odor ❑ Groundwater Contamination
uring UST Closure/Remova ❑ 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 one to indicate primary source) (Check one to indicate primary cause) (Check one) (Check on dicate primary product type released)
❑ Tank ❑ Spill Petroleum Gasoline/Diesel/ ❑ Diesel/Veg.Oil
❑ Pi i ❑ Overfill ❑ Non -Petroleum Kerosene Blend
Dispenser ❑ Corrosion ❑ Both ❑ Heating Oil ❑ Veg. Oil 100%
❑ Submersible Turbine Pump ❑ Physical/Mechanical Damage Location ❑ Other Petroleum ❑ E10 - E20
(Check one) Products ❑ E21 - E84
❑ Delivery Problem ❑ Install Problem
❑ Metals
Facility ❑ E85 - E99
Lo:❑Other (specify) ❑ Other (specify) ❑Other Inorganics
❑ Residence ❑ Ethanol 100%
❑ Unknown ❑ nknown ❑ Other Organics
Definitions printed on reverse Definitions pnnted on reverse ❑ Other ❑ E1 - E9
Ownership
5. Federal 6. County 7. State
1. Municipal 2. Military 3. Unknown EE)
Operation Type
1. Public Service 2. Agricultural 3. Residential 4. Education/Relig 5. Industrial Commercial 7. Mining
UST Form 61 (05/17) 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.)
2. N/A
3.
UST SYSTEM OWNER
UST Owner / Company: Circle K Stores, Inc.
Point of Contact: Alan Cubberley
Address: 1100 Sltus Court, Suite 100
City: Raleigh
State: NC
Zip Code:27606
Telephone Number: 919-774-6700
UST SYSTEM OPERATOR
UST Owner / Company: Circle K Stores, Inc - See above
Point of Contact:
Address:
City:
State:
Zip Code:
Telephone Number:
LANDOWNER AT LOCATION OF UST INCIDENT
UST Owner / Company: Craver James Properties, LLC, a NC LLC
Point of Contact: Unknown
Address: PO BOX 526
City: Concord
State: NC
Zip Code: 28026
Telephone Number: Unknown
Draw Sketch of Area (showing two major road intersections) or Attach Map
See attached.
Person Reporting Incident
Erin Greene
Company ATC Associates of NC
Telephone Number
704-529-3200
Title Project Manager
1 g
Address7606 Whitehall Executive Center Dr, Ste 800
Telephone Number
Charlotte, NC 28273
UST Form 61 (05/17)
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)
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)
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)
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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Cabarrus County shall not be held liable for any errors in the data represented on this record. This includes errors of omission,
commission, concerning the content of the data, and relative positional accuracy of the data. The data cannot be construed to be a
legal document. Primary sources from which this data was compiled must be consulted forverification of information represented
on this map document.
Physical 3065 DALE EARNHARDT BLVD KANNAPOLIS PIN14: 56227807710000
Address: NC 28083
Account Name CRAVER JAMES PROPERTIES LLC Account Name A NC LIMITED LIABILITY
1: 2: COMPANY
Mailing Address: P O BOX 526 Mailing City: CONCORD
Mailing State: NC Mailing Zip 28026
Property Real
ID:
Plat Page:
Units Type:
Building Value:
Assessed Value
Sale Year:
Sale Price:
Deed Page:
Zoning:
Middle School:
Precinct Name
Floodway:
500 Yr Flood
FIRM Panel
Number
04-086D-0002.00
00055
AC
null
null
2000
1750000
0130
C-2
undefined
No
No
5622
Code:
Plat Book:
Land Units:
Land Value:
OBXF Value:
Market Value:
Sale Month:
Deed Book:
Fire District:
Elementary
School:
High School:
Legal
Description:
100 Yr Flood:
Watershed
00035
1.14
AC
null
null
12
3071
P/O LT 2 COPPERFIELD
NORTHEAST
No
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Beverly, Trudy
From: Taraban, Ron
Sent: Friday, June 25, 2021 7:22 AM
To: Beverly, Trudy
Subject: FW: [External] Facility 036129 - UST61
Attachments: 2021-06-17_2723470_Form UST-61.pdf
Hi Trudy,
This popped up in my unread mail this morning.
thanks
From: Erin Greene <[e-mail]>
Sent: Wednesday, June 16, 2021 5:57 PM
To: Taraban, Ron <[e-mail]>
Cc: Mike Shaw <[e-mail]>; Rachel Capps <[e-mail]>
Subject: [External] Facility 036129 - UST61
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Good evening, Ron.
Please see the attached UST-61 for the above -referenced facility. Somehow, the report completion and analytical results
got overlooked. Apologies for the significant delay.
Let us know if you have any questions.
Thanks.
Erin E. Greene I PROJECT MANAGER I ATC Group Services LLC
Direct Dial [phone] Mobile [phone] Main Office [phone]
;ETC
7606 Whitehall Executive Center Drive, Suite 800 1 Charlotte, NC 28273
erin.greene0atcgs.com I www.atcgroupservices.com
Pronouns I use - She/her
On July 1, 2021, we will be known as Atlas! As Atlas, we will offer materials testing and inspection, construction quality assurance,
environmental, engineering and design, program management and construction support services to both public and private sector
clients. Our national network of professionals provide a broad range of technical services, helping clients test, inspect, certify, plan,
design, and manage a wide variety of projects across diverse end markets. For more information, please visit www.oneatlas.com.
Also on July 12, 2021 my email will change to erin.greene0oneatlas.com.
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