MO-292081_48272_CA_UST-61_20220119_24-Hour 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) Y
Facility ID Number _N/A_
Incident # Risk (H,I,L,U)
Confirmed GW Contamination? (Y/N)
Date Leak Discovered 1/13/22_
Received On Received By
Confirmed Soil Contamination ?(Y/N) _N
Comm/Non-Commercial? _Non_
Reported by (circle one): Phone, Fax or Report
Samples Taken?(Y/N) Y
Reg/Non-regulated? Non_
Region
Free Product? (Y/N) _N If Yes, State
Greatest Thickness
INCIDENT DESCRIPTION
Incident Name: 726 West Sugar Creek
Address: 726 West Sugar Creek
County: Union
Regional Office (circle one): Asheville, Mooresville, Fayetteville,
City/Town: Charlotte, NC
Zip Code: 28213
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): 35.26907 Longitude (decimal degrees) :-80.79428
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
550-gallon out of service heating oil underground storage tank (UST). Suspected impacted soils were excavated as
part of IAA activities. os-excava ion con Irma ion soil sample analytical results are expected o be received by
January 21 2022. Pending the analytical results additional impacted soils may be excavated. The results of the UST
xOther Google Earth
Describe location: UST
removal activities will be presented to DEQ in an IAA report.
Location
HOW RELEASE WAS DISCOVERED (Release code)
(Check one)
Release Detection Equipment or Methods x Visual/Odor ❑Groundwater Contamination
x 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)
X Tank Spill X Petroleum Gasoline/ Diesel/ ❑ Diesel/Veg. Oil
Piping Overfill Non -Petroleum Kerosene Blend
X Heating Oil ❑ Vegetable Oil 100%
Dispenser Corrosion Both Other
❑ E10 — E20
Submersible Turbine Pump Physical/Mechanical Location Petroleum
Damage Products ❑ E21 — E84
Delivery Problem (Check one)
Install Problem Metals ❑ E85 — E99
Spill Bucket
Other Facility Other Inorganics [:]Ethanol 100%
Other
X Unknown X Residence Other Organics ❑ E01 — E09
Unknown
Other
Definitions presented on reverse
Definitions resented 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
DreamKey Partners
Point of Contact
Address
Mr. Alex Walker
4601 Charlotte Park Drive, Suite 350
City
State
Zip Code
Telephone Number
Charlotte
NC
28217
414-617-5934
UST SYSTEM OPERATOR
UST Operator/Company
Address
Unknown
City
State
Zip Code
Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
Address
Same
City
State
Zip Code
Telephone Number
Draw Sketch of Area (showing two major road intersections) or Attach Map
Person Reporting Incident Steve Libbey
Company Hart & Hickman
Telephone Number 704-302-4404
Title Project Manager
Address 2923 South Tryon Street, Charlotte, NC
Date 01/19/22
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

Polaris 3G Map — Mecklenburg County, North Carolina
Date Printed: 1/19/2022 10:39:42 AM
4P /P 1,
O f' Sins^.
/ ti I rE,F'_35 f}11�M �- �•__. V GZ [ `�', it I ~�
el j
DevelopedIi� -� to �� r �j�, r �� /!y
'11A
if �
�'rKjflq . +131a9
:'�"`~ f ��'�. � `��� '� •.N, � � � �r iF----------_��"nxer st ___ ------ • .�` _� 'fie
CL
/
't
� `♦ � �+ � �_"._�. � Y J � .� tt � ,/aj �k � _� _. L:�� ter'
r 1
�r •` �•+ �� ` + ! tr •�'�• `'`"`-�Aw
J+1 , -- - - -- A��.��~' ;1 ice_ -•'r_ l 1t La 'r• L'
I
e.
•'`- �• � Rra� .J �{; r�llll � � y� i + y�f ~r f r � � • � J • , ti � �� 1l
N+
0 0.01251.025 0.05-Milesy,!
l l l • I I I i • �. t•_ I ' I ter'- � .L] �i i
TI
Phis maporreport is prepared for the inventory of real property within Mecklenburg County and is compiled from recorded deeds, plats, tax maps, surveys, planimetric maps, and other public records and data.
Jsers of this map or report are hereby notified that the aforementioned public primary information sources should be consulted for verification. Mecklenburg County and its mapping contractors assume no legal

Beverly, Trudy
From: Beverly, Trudy
Sent: Wednesday, January 19, 2022 11:56 AM
To: Steve Libbey
Subject: RE: [External] Home Heating Oil UST Release; 724 West Sugar Creek, Charlotte, NC
Hey Steve,
I handle unregulated usts for Mecklenburg county. The UST-61 got to the correct project manager. Document
received. Please email future documentation related to the release to me.
Have a wonderful day,
Trudy
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
_ North Carolina Department of Environmental Quality
EQ�� NR,vN7en[al �� �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: Steve Libbey [mailto:[e-mail]]
Sent: Wednesday, January 19, 2022 11:12 AM
To: Beverly, Trudy <[e-mail]>
Subject: [External] Home Heating Oil UST Release; 724 West Sugar Creek, Charlotte, NC
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Hi Trudy, please find attached a 24-Hour Release Notice for a heating oil UST removed at the above -referenced
address. Please let me know if it needs to be sent to someone else.
Please call me if you have any questions or would like to discuss the UST closure activities.
Thanks,
Steve

gwm LIbbey, PM Pro jest Mmgw
Here i Hlekmm% PC
9 0 Tryon Sbwe. Suke 100 - Chwlotto. NC 20
wrrr�h■rftI=n.com I ea 0