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Home My WebLink AboutMO-28779_48005_CA_UST-61_20210423_24-Hour Release and UST Leak Reporting FormUST-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) No Facility ID Number 05-026843 Incident # Risk (H,I,L,U) Confirmed GW Contamination? (Y/N) No Date Leak Discovered April 22, 2021 Received On Received By Confirmed Soil Contamination ?(Y/N) Yes Comm/Non-Commercial? Non Reported by (circle one): Phone, Fax or Report Samples Taken?(Y/N) No Reg/Non-regulated? Non Region Free Product? (Y/N) No If Yes, State Greatest Thickness INCIDENT DESCRIPTION Incident Name: Carolinas Medical Center Central Energy Plant Address: 1130 Blythe Blvd County: Mecklenburg Regional Office (circle one): Asheville, Mooresville, Fayetteville, City/Town: Charlotte Zip Code: 28204 Raleigh, Washington, Wilmington, Winston-Salem Latitude (decimal degrees): 35.20007042585996 Longitude (decimal degrees) :-80.83907586960213 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 Google Maps ❑Unknown Adjacent construction activities appear to have caused damage to double -walled flex pipe connected to USTs. Piping was exposed during nearby excavation and heating/fuel oil release was discovered following subsequent operation of boilers and emergency enerators within the Central Energy Plant. Less than 50 gallons of material has been released and resulting contaminated soil has been contained. No impacts to groundwater have been observed or suspected. Describe location: Additional excavation to locate and replace damaged pipe is planned while removal of contaminated soil is performed. Parking lot & Construction Site 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 OOther (specify) Nearby Construction 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 Q Petroleum ❑ Gasoline/ Diesel/ ❑ Diesel/Veg. Oil Q Piping ❑ Overfill ❑ Non -Petroleum Kerosene Blend 0 Heating Oil ❑ Vegetable Oil 100% ❑ Dispenser ❑Corrosion ❑Both ❑ Other Petroleum ❑ E10 — E20 ❑ Submersible Turbine Pump ❑Physical/Mechanical Location Products ❑ (Check one) Metals Delivery Problem Damage ❑ E21 — E84 ❑ ❑ Install Problem ❑ E85 — E99 ❑ Spill Bucket ❑ Other Inorganics 0 Other OFacility ❑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 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) 1. 2. 3. UST SYSTEM OWNER UST Owner/Company CHARLOTTE MECKLENBURG HOSPITAL AUTHORITY Point of Contact Address Gregory Mackin PO BOX 32681, 1000 BLYTHE BOULEVARD City State Zip Code Telephone Number Charlotte NC 28232-2681 704.996.4740 UST SYSTEM OPERATOR CHARLOTTE MECKLENBURG HOSPITAL AUTHORITY dba CAROLINAS MEDICAL CENTER UST Operator/Company Address CAROLINAS MEDICAL CENTER - CENTRAL ENERGY PLANT 1130 BLYTHE BOULEVARD City State Zip Code Telephone Number Charlotte NC 28204 704.996.4740 LANDOWNER AT LOCATION OF UST INCIDENT Landowner Address CHARLOTTE MECKLENBURG HOSPITAL AUTHORITY PO BOX 32681, 1000 BLYTHE BOULEVARD City State Zip Code Telephone Number Charlotte NC 28232-2681 704.996.4740 Draw Sketch of Area (showing two major road intersections) or Attach Map SEE ATTACHED AERIAL PHOTO Person Reporting Incident Company ATRIUM HEALTH Telephone Number 704.996.4740 Title Gregory Mackin, Sr. Specialist Address 900 Center Park Dr, Suite J, Charlotte, NC 28217 Date April 23, 2021 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 7 Google Maps X 9 35°12'00.3"N SO'50'20.7"W - Go X + — C X F G 1? 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(� A711Ri1-711Ar■■■ , A-,,� ir is Beverly, Trudy From: Beverly, Trudy Sent: Monday, April 26, 2021 7:57 AM To: Mackin, Gregory N Cc: Taraban, Ron; Grosso, Thomas J; Monago, Gene V; Bost, Larry; Peebles, Jimmy M; Halliburton, Paul W; Jones, Clarence Subject: RE: [External] 24-Hour Release Report - Carolinas Medical Center - Central Energy Plant - Charlotte, NC - Facility ID Number 05-00-026843 Good Morning Greg, Ron forwarded the 24-Hour Release form to me. I handle non -regulated underground storage tank releases for Mecklenburg county. Please send any additional documentation my way for review. Thank you and have a wonderful day, Trudy Trudy Beverly, L.G. Hydrogeologist, Division of Waste Management North Carolina Department of Environmental Quality UST Section, Mooresville Regional Office rm�e,rt o1 G,rmvn mencv 6u.y� 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: https://deq.nc.gov/about/divisions/waste-management/ust Branch's Above Ground Storage Tanks Website Address: https://deq.nc.gov/about/divisions/waste-management/ust/ast-program INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES: https://deq.nc.gov/about/divisions/waste-management waste -management -rules -data waste-mana ee ment_ ie s-mates File Review Procedures: https://deg.nc. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche): fts://deq.nc.gov/about/divisions/waste-manaizement/laserfiche Document Submittal & UST File Names for Laserfiche Policies: https://files.ne.gov/nedecl/W aste%20Management[D WM/UST/W hatsNew/Final-Electronic-Document-Submittal-Policy.pdf https:Hfiles.nc. gov/ncdeq/Waste%2OManagement/D WM[UST/Corrective%2OAction/UST%2Ofile%20names%20for%2OLaserfiche.docx From: Taraban, Ron Sent: Monday, April 26, 2021 7:32 AM To: Beverly, Trudy <trudy.beverly@ncdenr.gov> Subject: FW: [External] 24-Hour Release Report - Carolinas Medical Center - Central Energy Plant - Charlotte, NC - Facility ID Number 05-00-026843 Hi Trudy, We can discuss if we need to. thanks From: Mackin, Gregory N <Gregory.Mackin @atriumhealth.org> Sent: Friday, April 23, 2021 1:59 PM To: Taraban, Ron <ron.taraban@ncdenr.gov> Cc: Grosso, Thomas J <Thomas.Grosso@atriumhealth.org>; Monago, Gene V <Gene.Monago@atriumhealth.org>; Bost, Larry <Larry.Bost@atriumhealth.org>; Peebles, Jimmy M <Jimmy.Peebles@atriumhealth.org>; Halliburton, Paul W <Paul.Halliburton@atriumhealth.org>; Jones, Clarence <Clarence.Jones@atriumhealth.org> Subject: [External] 24-Hour Release Report - Carolinas Medical Center - Central Energy Plant - Charlotte, NC - Facility ID Number 05-00-026843 CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to Report Spam. Ron — attached you will find the subject release report form for the subject site. We have observed and contained a small petroleum release (heating/fuel oil) from fuel pipes associated with the underground storage tanks at our Central Energy Plant. We believe the release is due to construction and excavation activities occurring on areas adjacent to and above where the fuel lines are located. We have isolated the lines to prevent further release and plan to perform additional excavation to remove contaminated soil, locate and repair the damaged pipes. You may contact me directly to discuss the release at your earliest convenience. Thanks, Greg Mackin - PE, CHFM, MSE Senior Specialist Plant Operations Support Services Atrium Health Carolinas Health Care System is Atrium Health Mobile: 704-996-4740 Phone:704-667-9443 Email: Gregory. Mackin(a)AtriumHealth.org Mailing: 900 Center Park Dr, Suite J, Charlotte, NC 28217 This electronic message may contain information that is confidential and/or legally privileged. It is intended only for the use of the individual(s) and entity named as recipients in the message. If you are not an intended recipient of this message, please notify the sender immediately and delete the material from any computer. Do not deliver, distribute or copy this message, and do not disclose its contents or take any action in reliance on the information it contains. Thank you.