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Home My WebLink AboutMO-29035_48226_CA_UST-61_20220124_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) Facility ID Number Incident # Risk (H,I,L,U) Confirmed GW Contamination? (Y/N) N Date Leak Discovered 1/21/21 Received On Received By Confirmed Soil Contamination ?(Y/N) y Comm/Non-Commercial? OC Reported by (circle one): Phone, Fax or Report Samples Taken?(Y/N) y Reg/Non-regulated? NR Region Free Product? (Y/N) N If Yes, State Greatest Thickness INCIDENT DESCRIPTION Incident Name: 715 DannaDolis Darkld a0 Address: 715 laannaDolis DarkM a0 County: CalaarrOs Regional Office (circle one): Ashevill Mooresville ayetteville, City/Town: Concord Zip Code: 28027 Raleigh, Washington, Wilmington, WinsF5'R'-STMrFF Latitude (decimal degrees): 35.424684 Longitude (decimal degrees) : 801JE78730 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 ❑x Other ❑ Unknown Describe location: A release of diesel f0el was identified upon receipt of laboratory data associated with soil samples collected during UST system removal activities. Free product was not observed. HOW RELEASE WAS DISCOVERED (Release code) (Check one) ❑Release Detection Equipment or Methods ❑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) ❑ Tank ❑ Spill ❑X Petroleum M Gasoline/ Diesel/ ❑ Diesel/Veg. Oil ❑ Piping ❑ Overfill ❑ Non -Petroleum Kerosene Blend Heating Oil ❑ Vegetable Oil 100% ❑Dispenser Corrosion Both ❑ ❑❑ ❑ Other Petroleum ❑ El — E20 ❑ Submersible Turbine Pump ❑ Physical/Mechanical Location Products ❑ Delivery Problem Damage (Check one) Metals ❑ E21 — E84 ❑ ❑ Install Problem ❑ E85 — E99 ❑ Spill Bucket ❑ Other Inorganics ❑ Other [:]Facility Other 100% ❑ Other ❑ Other Organics ❑x Unknown ❑X 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 gzesiden ' 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 3cjn now 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 BV 715 Kannapolis Parkway, LLC Point of Contact Address Lee Easley 1414 Yanceyville Street, Ste 300 City State Zip Code Telephone Number Greensboro NC 27405 336-553-3785 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 Attached Person Reporting Incident Jason Ricks Company Pilot Geological, PLLC Telephone Number 336-870-3095 Title Principal Geologist Address PO Box 128, Kernersville, NC 27285 Date 1/24/21 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 Beverly, Trudy From: Beverly, Trudy Sent: Monday, January 24, 2022 6:35 AM To: Jason Ricks Cc: Lee Easley Subject: RE: [External] 715 Kannapolis Pkwy, Concord Received. Trudy Trudy Beverly, L.G. D-�IE Hydrogeologist, Division of Waste Management North Carolina Department of Environmental Quality IFepnrlren[ol Gma'nn mental4w UST Section, Mooresville Regional Office 704.235.2182 (Office) Trudy. B everlyAncdenn 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://deg.nc.gov/about/divisions/waste-management/ust Branch's Above Ground Storage Tanks Website Address: hit2s://deq.nc.gov/about/divisions/waste-management/ust/ast-pro2Tam INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES: hops://deq.nc.gov/about/divisions/waste-management/waste-management-rules-data/waste-mana eg ment ig s=mats File Review Procedures: hops://deq.ne. 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: httns:Hflles.ne.izov/nedeafWaste%2OManasement/DWM/UST[WhatsNew/Final-Electronic-Document-Submittal-Policv.l)df https:Hfiles.nc.gov/ncdeq/Waste%20Management/D WM/UST/Corrective%2OAction/UST%2Ofilc%20names%20for%2OLaserfiche.docx From: Jason Ricks [mailto:JRicks@pilotenviro.com] Sent: Saturday, January 22, 2022 3:25 PM To: Beverly, Trudy <trudy.beverly@ncdenr.gov> Cc: Lee Easley <leasley@biscuitville.com> Subject: [External] 715 Kannapolis Pkwy, Concord CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to Report Spam. Beverly, I hope all is well. Please see the attached UST-61. We should have the report to you on Monday and the NORP you at some point next week. There is a property transaction pending with a tight time frame for closing. Please send the incident number as soon as you can. Thanks and let me know if you have any questions. Sincerely, Jason Ricks, LG 336.870.3095 (c) 336.310.4527 (o) PO Box 128 Kernersville, NC 27285 WWW.Pilotenviro.com &ricks@pilotenvirc .com