FA-29729_48845_CA_SCH_20230116

3502 Hayes Road • Monroe, North Carolina 28110
113 West Firetower Road, Suite G • Winterville, North Carolina 28590
Phone [phone] • [phone] • Fax [phone]
January 13, 2023

Mr. Ken Currie
NCDEQ-UST Section
Fayetteville Regional Office
Systel Building
225 Green Street, Suite 714
Fayetteville, NC 28301-5043

Re: Site Check Report
Laurinburg Food Mart
1201 Produce Market Road
Laurinburg, Scotland County
North Carolina
Facility ID Number: 00-0-0000009375
Incident Number: Pending
GRI Project Number: 4098

Dear Mr. Currie,

Please find attached the referenced revised, report for the abovementioned site.
If you have any questions, please contact William Regenthal at 704-845-4010.

Sincerely,
Geological Resources, Inc.

Leslie Maxtone-Graham
Administrative Assistant

Enclosure

Cc: Mr. Walter Jones; Gibson Oil & Gas Company, file

3502 Hayes Road • Monroe, North Carolina 28110
113 West Firetower Road, Suite G • Winterville, North Carolina 28590
Phone [phone] • [phone] • Fax [phone]
Engineering Certification: C-2727 • Geology Certification: C-127
Site Check Report
Laurinburg Food Mart
1201 Produce Market Road
Laurinburg, Scotland County
North Carolina
Facility ID Number: 00-0-000009375
Incident Number: Pending
GRI Project Number: 4098

Prepared for:

Gibson Oil & Gas Company, Inc.
9340 Morgan Street
Laurel Hill, North Carolina 28352

January 13, 2023

William Regenthal, P.G.
Project Manager
Blake Butcher
Staff Scientist

___________________________________________________________________________________________
Prepared by: Geological Resources, Inc. Site Check Report
Prepared on: January 13, 2023 Laurinburg Food Mart
Project Manager: William Regenthal, P.G. GRI Project No. 4098
i
EXECUTIVE SUMMARY
The Laurinburg Food Mart site is located at 1201 Produce Market Road in Laurinburg, Scotland County,
North Carolina. The property operates as a petroleum retail facility and convenience store. The site is
covered by concrete, asphalt and grass. There are one 8,000-gallon regular gasoline, one 6,000-gallon
plus gasoline and one 4,000-gallon premium gasoline USTs currently in use at the site with four associated
dispenser islands. One 1,000-gallon kerosene UST was removed from the site in March 2016. A release
was observed during the March 2016 UST closure activities and UST Incident Number 29993 was issued.
This incident was closed with a NFA on September 28, 2016.

On January 4, 2023, GRI conducted a site check in the area of the 8,000-gallon regular gasoline UST spill
bucket. One soil sample (Reg. Spill Bucket (2’)) was collected beneath the failed spill bucket while repairs
were being completed. The soil sample was submitted for analysis of TPH-GRO using UVF technology. A
concentration of TPH-GRO that exceeded the RAL was reported in soil sample Reg. Spill Bucket (2’).

Based on this information, a soil quality violation exists and further assessment is warranted at the site.

___________________________________________________________________________________________
Prepared by: Geological Resources, Inc. Site Check Report
Prepared on: November 19, 2021 Home Race Mart #1
Project Manager: Ethan Rogerson, G.I.T. GRI Project No. 5836

iii
ACRONYMS
ACM: Asbestos Containing Materials
AFVR: Aggressive Fluid-Vapor Recovery
ARR: Acknowledgement of Report Receipt
AS: Air Sparging
AST: Aboveground Storage Tank
ASTM: American Society for Testing and
Materials
BGS: Below Ground Surface
CAP: Corrective Action Plan
CFR: Code of Federal Regulations
CSA: Comprehensive Site Assessment
DPE: Dual Phase Extraction
DRO: Total Petroleum Hydrocarbons Diesel
Range Organics
DWM: Division of Waste Management
DWR: Department of Water Resources
EPA: Environmental Protection Agency
EPH: Extractible Petroleum Hydrocarbons
ESA: Environmental Site Assessment
GCL: Gross Contamination Level
GRI: Geological Resources, Inc.
GRO: Total Petroleum Hydrocarbons
Gasoline Range Organics
LSA: Limited Site Assessment
MAC: Maximum Allowable Concentration as
specified in T15A NCAC 2L.0202
MADEP: Massachusetts Department of
Environmental Protection
MCC: Maximum Contaminant Concentrations
MMPE: Mobile Multi-Phase Extraction
NAPL: Non-Aqueous Phase Liquid, “Free
Product”
NCDEQ: North Carolina Department of
Environmental Quality
NCDOT: North Carolina Department of
Transportation
NFA: Notice of No Further Action
NORR: Notice of Regulatory Requirements
NOV: Notice of Violation
NPDES: National Pollutant Discharge
Elimination System
NRP: Notice of Residual Petroleum
O&M: Operation and Maintenance
PAHs: Polynuclear Aromatic Hydrocarbons
PCA: Pre-Construction Assessment
RAL: Regulatory Action Level
SCLs: Soil Cleanup Level
SPCC: Spill Prevention Control and
Countermeasures
SVE: Soil Vapor Extraction
SVOCs: Semi-Volatile Organic Compounds
SWPPP: Stormwater Pollution Prevention Plan
TCLP: Toxicity Characteristic Leaching
Procedure (EPA Method SW-846 1311)
TOC: Top of Casing
TPH: Total Petroleum Hydrocarbons
USGS: United States Geological Survey
UST: Underground Storage Tank
UVF: Ultraviolet Fluorescence
VOCs: Volatile Organic Compounds
VPH: Volatile Petroleum Hydrocarbons

___________________________________________________________________________________________
Prepared by: Geological Resources, Inc. Site Check Report
Prepared on: January 13, 2023 Laurinburg Food Mart
Project Manager: William Regenthal, P.G. GRI Project No. 4098

TABLE OF CONTENTS

EXECUTIVE SUMMARY ....................................................................................................................... i
SITE INFORMATION ............................................................................................................................ ii
ACRONYMS ....................................................................................................................................... iii
A. SITE HISTORY AND CHARACTERIZATION .............................................................................1
B. SITE CHECK PROCEDURES...................................................................................................2
C. SITE INVESTIGATION ..........................................................................................................2
D. SUMMARY AND CONCLUSIONS ..........................................................................................3
E. LIMITATIONS .....................................................................................................................3

FIGURES
Figure 1: Site Location Map
Figure 2: Site Map
Figure 3: Soil Quality Map

TABLES
Table 1: UST Owner/Operator Information
Table 2: UST System Information
Table 3: Summary of Soil Sample Analytical Results

APPENDICES
Appendix A: NCDEQ Correspondence
Appendix B: UST-61 Form
Appendix C: UVF Analytical Report

___________________________________________________________________________________________
Prepared by: Geological Resources, Inc. Site Check Report
Prepared on: January 13, 2023 Laurinburg Food Mart
Project Manager: William Regenthal, P.G. GRI Project No. 4098
1
A. SITE HISTORY AND CHARACTERIZATION
1. UST Owner and Operator Information:
In accordance with the Site Check Report guidelines, the UST owner and operator information has been
summarized in the attached Table 1.

2. UST System Information:
In accordance with the Site Check Report guidelines, the UST system information has been summarized
in the attached Table 2. There are one 8,000-gallon regular gasoline, one 6,000-gallon plus gasoline,
and one 4,000-gallon premium gasoline USTs currently in use at the site with four associated dispenser
islands. One 1,000-gallon kerosene UST was removed from the site in March 2016. A release was
observed during the March 2016 UST closure activities and UST Incident Number 29993 was issued.
This incident was closed with a NFA on September 28, 2016. Please note, the NCDEQ Registered Tank
Report has not been updated to show that the 1,000-gallon kerosene UST has been removed. A copy
of the NCDEQ Registered Tank Report is shown below:

3. Non-UST Information:
There are currently no ASTs at the site.

4. Comprehensive Description of the Release:
On August 30, 2022, compliance testing was conducted. The spill bucket associated with the 8,000-gallon
regular gasoline UST spill bucket compartment received non-passing test results. NCDEQ correspondence
is included as Appendix A.

On January 4, 2023, one soil sample (Reg. Spill Bucket (2’)) was collected beneath the failed spill bucket

___________________________________________________________________________________________
Prepared by: Geological Resources, Inc. Site Check Report
Prepared on: January 13, 2023 Laurinburg Food Mart
Project Manager: William Regenthal, P.G. GRI Project No. 4098
2
as repairs were being completed. Upon receipt of the analytical results on January 6, 2023, a release was
confirmed at the site. A UST-61 Form was submitted to the NCDEQ incident manager on January 13, 2023.
A Copy of the UST-61 Form is included as Appendix B.

5. Description of the Site Characteristics:
The Laurinburg Food Mart site is located at 1201 Produce Market Road in Laurinburg, Scotland County,
North Carolina. (Figure 1). The property operates as a petroleum retail facility and convenience store.
The site is covered by concrete, asphalt, and grass. There are one 8,000-gallon regular gasoline, one 6,000-
gallon plus gasoline, and one 4,000-gallon premium gasoline UST currently in use at the site with four
associated dispenser islands. One 1,000-gallon kerosene UST was removed from the site in March 2016.
The surrounding properties are residential. A Site Map has been included as Figure 2.

B. SITE CHECK PROCEDURES
1. Results of Tank and Line Tightness Testing:
On January 6, 2023, the spill bucket associated with the 8,000-gallon regular gasoline UST received passing
tightness testing results. A copy of the passing results is provided in Appendix A.

2. Summary of Site Check Procedure:
On January 4, 2023, GRI performed a site check that included collecting a soil sample beneath the spill
bucket associated with the 8,000-gallon regular gasoline UST while repairs were being completed. One
soil sample (Reg. Spill Bucket (2’)) was collected approximately 2 feet BGS and was submitted for UVF
analysis of TPH-GRO.

3. Soil Excavation Activities:
No soil excavation activities were conducted.

C. SITE INVESTIGATION
1. Field Screening:
No field screening activities were conducted.

2. Soil Sampling Information:
A concentration of TPH-GRO that exceeded the RAL was reported in the soil sample collected from Reg.
Spill Bucket (2’). No free product was noted at the site. A soil quality map is presented as Figure 3. A
summary of soil sample analytical result is presented in Table 3. The UVF analytical report is provided as
Appendix C. A summary of the soil sampling data from the January 2023 Site Check activities is shown
below:

___________________________________________________________________________________________
Prepared by: Geological Resources, Inc. Site Check Report
Prepared on: January 13, 2023 Laurinburg Food Mart
Project Manager: William Regenthal, P.G. GRI Project No. 4098
3 Sample ID Sample Depth (ft-BGS) Gasoline-Range TPH Diesel-Range DRO RAL (mg/kg) 50 100
Soil to Water MCC (mg/kg) NE NE
Reg. Spill Bucket (2’) 2 207 NR

3. Ground Water and Surface Water Sampling Information:
A ground water sample was not collected.

4. Quality-Control Measures:
Clean, disposable nitrile gloves were used for the collection of the soil sample. The sample was collected
in laboratory supplied containers, transported following proper chain-of-custody procedures, and
analyzed within the applicable hold time.
D. SUMMARY AND CONCLUSIONS
 The site is a petroleum retail facility and convenience store, and the surrounding properties are
residential.
 A Site Check was conducted on January 4, 2023, to determine if a petroleum release had occurred.
 One soil sample (Reg. Spill Bucket (2’)) was collected approximately 2 feet BGS beneath the spill
bucket as repairs were being completed.
 A concentration of GRO that exceeded the RALs was reported in the collected soil sample (Reg.
Spill Bucket (2’)).
 On January 6, 2023, the spill bucket associated with the 8,000-gallon regular gasoline UST received
passing tightness testing results.
 Based on this information, a soil quality violation exists and further assessment is warranted for
this site.

E. LIMITATIONS
This report has been prepared for the exclusive use of Gibson Oil & Gas Company Inc. for the specific
application to the referenced site in Scotland County, North Carolina. The assessment was conducted
based on the scope of work and level of effort specified by NCDEQ and with resources adequate only for
that scope of work. Our findings have been developed in accordance with generally accepted standards
of geology and hydrogeology practices in the State of North Carolina, available information, and our
professional judgment. No other warranty is expressed or implied.
The data that are presented in this report are indicative of conditions that existed at the precise locations
sampled and at the time the samples were collected. In addition, the data obtained from samples would
be interpreted as being meaningful with respect to parameters indicated in the laboratory report. No

___________________________________________________________________________________________
Prepared by: Geological Resources, Inc. Site Check Report
Prepared on: January 13, 2023 Laurinburg Food Mart
Project Manager: William Regenthal, P.G. GRI Project No. 4098
4
additional information can logically be inferred from these data.

FIGURES
SITE LOCATION
Figure 1
Site Location
Laurinburg Food Mart
1201 Produce Market Road
Laurinburg, North Carolina
Scotland County
Incident No. Pending
GRI Project No. 4098
500 M
2000 FT
Date: 01/10/2023 Location: 36.012822°N -77.860330°W
D
a
d

TABLES
UST ID Number 1-3 Facility ID Number
Owner or Operator?
Owner
UST ID Number 4 Facility ID Number
Owner or Operator?
Owner
Address Telephone Number
9340 Morgan Street, Laurel Hill, NC 28351-9362 [phone]
00-0-0000009375
Name of Owner or Operator Dates of Ownership / Operation
Gibson Oil & Gas Company, Inc.04/28/1984 - 03/29/2016
TABLE 1
UST OWNER/OPERATOR INFORMATION
LAURINBURG FOOD MART (INCIDENT NO. PENDING)
Dates of Ownership / OperationName of Owner or Operator
00-0-0000009375
Telephone NumberAddress
04/28/1984 - CurrentGibson Oil & Gas Company, Inc.
(910) 462-21559340 Morgan Street, Laurel Hill, NC 28351-9362
Page 1 of 1
Date: 01/11/2023
Was Release
Associated
with UST
System?
(Yes / No)
1 Gasoline Gasoline 8,000 04/28/1984 Steel 8' x 21'4"Steel Active No
2 Gasoline Gasoline 6,000 04/28/1984 Steel 8' x 16'Steel Active No
3 Gasoline Gasoline 4,000 04/28/1984 Steel 64" x 24'Steel Active No
4 Kerosene Kerosene 1,000 04/28/1984 Steel 64" x 72"Steel Removed
(03/29/16)Yes
LAURINBURG FOOD MART (INCIDENT NO. PENDING)
TABLE 2
UST SYSTEM INFORMATION
Capacity
(gallons)
Tank
Dimensions
Status
of
UST
UST
ID
No.
Current
or Most
Recent
Contents
Previous
Contents
Construction
Details
Description of
Associated
Product Piping
and
Pumps
Date
Installed
Facility ID #: 00-0-0000009375
Page 1 of 1
Date: 01/11/23
Sample ID Date Collected
(mm/dd/yy)
Sample
Depth
(feet)
10 10 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA
NE NE 0.0072 5.4 8.0 6.0 0.085 0.20 1.4 6.6 0.054 1.5 68 540 31 540 NE 31
NE NE 12 1,250 60 3,120 156 5.5 1,560 156 22.8 63 625 1,560 469 1,560 31,200 469
DI-1-3'03/29/16 3 391 1,270 <0.057 <0.051 0.549 1.01 <0.050 8.88 2.22 22.6 6.76 8.72 <32 651 520 1,700 <240 <360
UST-K-1-7'03/29/16 7 351 3,170 <0.0020 0.0039 J 0.0711 0.0103 J <0.0018 0.540 E 0.233 J <0.0016 3.33 4.51 <25 330 216 1,330 <130 245 J
STOCKPILE 0-200 03/29/16 0 942 3,630 NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR
Reg. Spill Bucket (2')01/04/23 2 207 NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR
Notes:
• Results reported in mg/kg (milligrams per kilograms)
• MCC: Maximum Contaminant Concentration level as specified by T 15A NCAC 2L.0202.
• RSCL: Residential Soil Cleanup Level as specified by T 15A NCAC 2L.0202.
• < : Less than the method detection limit specified in the laboratory report
• Concentrations in bold face type exceeded the soil to ground water MCCs.
• Concentrations in bold face and italicized type exceeded the RSCLs.
• NE: Not Established
• NR: Method Constituent Not Requested
• J: Estimated value.
• E: Value exceeds calibration range.
RAL (mg/kg)
Soil to Water MCC (mg/kg)
RSCLs (mg/kg)C9-C18 AliphaticsC19-C36 AliphaticsC11-C22 Aromatics1-Methylnaphthalene2-MethylnaphthaleneC5-C8 AliphaticsC9-C12 AliphaticsC9-C10 Aromatics1,2,4-Trimethylbenzenen-PropylbenzeneNaphthaleneMADEP EPH
Contaminant of Concern TPH-GROTPH-DROBenzeneTolueneEthylbenzeneXylenesMTBETABLE 3
SUMMARY OF SOIL SAMPLE ANALYTICAL RESULTS
LAURINBURG FOOD MART (INCIDENT NO. PENDING)
Facility ID No. 00-0-0000009375
Analytical Method EPA Method 8015C SW846 8270D MADEP VPHSW846 8260B

APPENDICES

Appendix A
NCDEQ Correspondence

Page 1 of 10 9/15/2022 11:11 AM
North Carolina
Department of Environmental Quality
Underground Storage Tank
UST-10BPrinted:9/15/2022 11:11 AM
Inspection Result:Failed Inspection Date:8/30/2022
Partial Inspection:No Arrive and Depart Times:12:45 PM-1:15 PM
Facility ID:00-0-0000009375 Inspector Gina Williams
Facility Name LAURINBURG FOOD MART Insp.Type Compliance
Facility Address 609 PRODUCE MARKET RD
LAURINBURG,NC 28352
Scotland County
Located facility,USTs onsite
Reason(s)Routine Compliance
Location 34.790369,-79.446122
Permit Exp.9/30/2022
Facility Phone [phone]
CONTACTS
Contact Type Contact Information
Regulatory Operator
since 3/2/2017
Amran S.Hussein,1201 Produce Market Rd.Laurinburf,NC 28352,Phone:(910)
276-7277
Owner
since 4/17/2003
GIBSON OIL &GAS CO INC ,9340 MORGAN STREET LAUREL HILL,NC
28351-9362,Phone:[phone]
Manager
since 11/6/2019
WALTER JONES,9340 MORGAN STREET LAUREL HILL,NC 28351,Phone:(910)
462-2155,Email:[e-mail]
OWNERSHIP CHANGE
New Owner Change Date Basis Transfer of Ownership Form (UST-15)Submitted
No
EMERGENCY RESPONSE
Emergency response placard with emergency response operator contact information is
posted in the dispensing areas if the dispensers are left on without an attendant present?
N/A
OTHER PARTICIPANTS
Name Organization
Hunter Evans Evans Environmental
INSPECTOR COMMENTS
Type Date Comment
ADDITIONAL INSPECTOR COMMENTS
Reg spill not tested
premium and plus has dw spill with visible gauge
TANKS AND PIPING INFORMATION
Tanks Tank #1(2 Plus)Tank #2(3 Premium)Tank #3(1 Regular)
Tank ID 2 Plus 3 Premium 1 Regular
TIMS Tank ID 2 3 1
Is tank registered?Yes Yes Yes
Date tank installed 4/28/1984 4/28/1984 4/28/1984
Capacity of Tank in Gallons 6000 4000 8000
Is tank regulated Yes Yes Yes
Diameter (Inches)
Tank /Product use Motor Fuel Motor Fuel Motor Fuel
Product stored in Tank Gasoline,Gas Mix Gasoline,Gas Mix Gasoline,Gas Mix
Product Detail BLANK BLANK BLANK
UST-10B Facility ID:00-0-0000009375
Page 2 of 10 9/15/2022 11:11 AM
Tanks Tank #1(2 Plus)Tank #2(3 Premium)Tank #3(1 Regular)
If hazardous substance,CAS#or
description
If other,description
Tank status Current Current Current
Tank closure report submitted
Date tank last operated
Inches of product in Tank
Compartment tank No No No
Other compartment(s)
Base compartment
Manifolded tank No No No
Manifolded with tank(s)
Master manifold tank
New Tank System installed in
accordance with NC or MI
N/A N/A N/A
Tank Construction Material (DW
required after 11/1/07)
Single Wall Steel Single Wall Steel Single Wall Steel
If other,description
Tank Manufacturer/Model Unknown Unknown Unknown
If other,describe
Tank material verified by UST-7A/B UST-7A/B UST-7A/B
Date Pipe Installed 4/28/1984 4/28/1984 4/28/1984
Was UST Piping Installed on or
after 11/1/2007?
No No No
Piping Construction Material (DW
required after 11/1/07)
Single Wall Steel Single Wall Steel Single Wall Steel
If other,description
Pipe Manufacturer/Model Unknown Unknown Unknown
If other,describe
Pipe material verified by UST-8 with Installer
Certification
UST-8 with Installer
Certification
UST-8 with Installer
Certification
If E-blend >10%or Biodiesel
Blend >20%;Was UST-20
completed and approved?
N/A N/A N/A
CORROSION PROTECTION
Tank Corrosion Protection Tank #1(2
Plus)
Tank #2(3
Premium)
Tank #3(1
Regular)
DWM notified of current CP method Yes Yes Yes
Integrity assessment performed after 3/1/06 No No No
CP Method 1 Impressed
Current
Impressed
Current
Impressed
Current
if other,Description
CP Installation Date 8/31/1997 8/31/1997 8/31/1997
CP Method 2
if other,Description
CP Installation Date
Flex Connector ,Piping Extensions,and/or other metal
fittings Present
Ball Valve,
Elbow,Flex
Connector,
Other Metal
Ball Valve,
Elbow,Flex
Connector,
Other Metal
Ball Valve,
Elbow,Flex
Connector,
Other Metal
Flex connector isolated from ground No No No
Source of verification of CP for Flex Connectors,piping
extensions and/or other metal fittings
CP Test
Results
CP Test
Results
CP Test
Results
if other,Description
Submersible pump (STP)is isolated from ground No No No
Piping extensions and/or other metal fittings are
isolated from ground
No No No
UST-10B Facility ID:00-0-0000009375
Page 3 of 10 9/15/2022 11:11 AM
Tank Corrosion Protection Tank #1(2
Plus)
Tank #2(3
Premium)
Tank #3(1
Regular)
Flex connector,STP and/or other metal fittings
protected from corrosion
Yes Yes Yes
Corrosion protection method Impressed
Current
Impressed
Current
Impressed
Current
Flex connector ,Piping extensions,and/or other metal
fittings CP Installation Date
8/31/1997 8/31/1997 8/31/1997
Dielectric Coating Installed (If tank installed after
12/22/88
N/A N/A N/A
Pipe Corrosion Protection Tank #1(2 Plus)Tank #2(3
Premium)
Tank #3(1
Regular)
DWM notified of current CP method Yes Yes Yes
CP method Impressed
Current
Impressed
Current
Impressed
Current
if other,Description
CP Installation Date 8/31/1997 8/31/1997 8/31/1997
Dielectric Coating Installed (If piping installed
after 12/22/88
N/A N/A N/A
Dispenser Corrosion Protection Dispenser
#1(Plus)
Dispenser
#2(Regular)
Dispenser
#3(Regular)
Dispenser
#4(Super)
Flex Connector ,Piping Extensions,
and/or other metal fittings Present
Flex
Connector,
Other Metal
Flex
Connector,
Other Metal
Flex
Connector,
Other Metal
Flex
Connector,
Other Metal
Flex connector isolated from ground Yes Yes Yes Yes
Source of verification of CP for Flex
Connectors,piping extensions and/or
other metal fittings
CP Test
Results
CP Test
Results
CP Test
Results
CP Test
Results
if other,Description
Piping extensions and/or other metal
fittings are isolated from ground
Yes Yes Yes Yes
Flex Connectors,Piping extensions
and/or other metal fittings protected
from corrosion
N/A N/A N/A N/A
Corrosion protection method Impressed
Current
Impressed
Current
Impressed
Current
Impressed
Current
Flex connector,Piping extensions,
and/or other metal fittings CP
Installation Date
Source of Information for verification of
corrosion protection for Riser pipe and
other metal piping
Visual Visual Visual Visual
if other,Description
CP Conclusions
CP Requirements Met?No
Issues CP System must be tested by qualified CP tester (MT1A/H &CL1
if TOS)
Impressed Current Systems IC System #1
Applies to Tanks #1(2 Plus),#2(3 Premium),#3(1 Regular)
Current Voltage (Gauge)55.0000
Current Amperage (Gauge)1.7000
UST-10B Facility ID:00-0-0000009375
Page 4 of 10 9/15/2022 11:11 AM
Impressed Current Systems IC System #1
Current Voltage (Multimeter)
Measured Shunt Voltage (mV)
Rectifier Shunt Factor (Amps/mV)
Amps -Calculated
Last three 60-day readings available No
System operating properly Yes
If no,select all that apply
If other,describe
Hour meter reading?
Hour meter installed No
CP Tests Test #1
Applies to Tanks #1(2 Plus),#2(3 Premium),#3(1
Regular)
Portion of System Tested Flex connectors,Piping,Tanks
Date of last Corrosion Protection Test 6/25/2019
CP Test Result Pass
Was CP Test done in accordance with National Standard?Yes
CP Tester Name Robert S.Howie
Certificate Number 2702
Certifying Organization NACE
CP Testing Company Name Enviro Consulting Inc
CP Testing Company Phone [phone]
As Left Voltage 31
As Left Current 1.8
UST7 form for last CP test submitted to DWM Yes
SPILL PREVENTION
Has DWM been notified of spill methods?Yes
Spill/Overfill Details Tank #1(2
Plus)
Tank #2(3
Premium)
Tank #3(1
Regular)
Is a drop tube present?Yes Yes Yes
Type of Stage I vapor recovery?Coaxial Coaxial Coaxial
Local Fill Tank #1(2
Plus)
Tank #2(3
Premium)
Tank #3(1
Regular)
Does Tank have a Second Fill?No No No
Spill Protection Catchment
Basin
Catchment
Basin
Catchment
Basin
Is spill prevention equipment provided and verified?Yes Yes Yes
Manufacturer/Model OPW:Edge
1C/1SC-3112X/
31512X (DW
w/gauge)
OPW:Edge
1C/1SC-3112X/
31512X (DW
w/gauge)
EMCO:Bucket
(SW)
If other,describe
Spill bucket is double-walled?Yes Yes No
Monitoring Type
(UST-6B)
Float Gauge
(Mech)
Float Gauge
(Mech)
Is spill bucket interstice monitored every 30 days?
(If installed before 11/1/07)
Yes Yes
Spill bucket is isolated or made of non-corroding
materials?(If installed after 11/1/07)
N/A N/A N/A
Date spill prevention provided 8/17/1997 8/17/1997 8/17/1997
Last 12 monthly spill bucket checks completed and
all deficiencies corrected (UST-27)?
Yes Yes Yes
UST-10B Facility ID:00-0-0000009375
Page 5 of 10 9/15/2022 11:11 AM
Local Fill Tank #1(2
Plus)
Tank #2(3
Premium)
Tank #3(1
Regular)
Is spill prevention operating properly?Yes Yes No
If No,select all that apply Hole/Defect,
Records not
available
If other,describe
O&M walkthrough inspection completed in
accordance with national standard (e.g.PEI RP 900)
(UST-27)?
Yes Yes
3 Year Tightness Test Date
(UST-6D/23A)
8/9/2022 8/9/2022
Primary Tightness Test Result
(UST-6D/23A)
Pass Pass Fail
Secondary Tightness Test Result
(UST-6D/23A)
Pass Pass
Tightness Testing done in accordance with a
standard?
Yes Yes
OVERFILL PREVENTION
Has DWM been notified of overfill methods?Yes
Overfill Control Tank #1(2
Plus)
Tank #2(3
Premium)
Tank #3(1
Regular)
Is overfill prevention equipment provided and
verified?
Yes Yes Yes
Date overfill control provided 8/17/1997 8/17/1997 8/17/1997
Type of overfill equipment Auto Shutoff
Device
Auto Shutoff
Device
Auto Shutoff
Device
Source of information for overfill control verification
If other,describe
Manufacturer/Model BLANK BLANK BLANK
If other,describe
Is overfill control operating properly?No No No
If No,select all that apply Incorrect
length/volume
Incorrect
length/volume
Incorrect
length/volume
If other,describe
Overfill check date (UST-22A)
Overfill check result (UST-22A)
Capacity of Tank in Gallons 6000 4000 8000
Diameter (Inches)
Dispenser Sumps Dispenser
#1(Plus)
Dispenser
#2(Regular)
Dispenser
#3(Regular)
Dispenser
#4(Super)
Are containment sumps present?No No No No
Installation Date
Sump Manufacturer
If Other (Specify)
Sump Construction Type
Sump Construction Material
If Other (Specify)
Are containment sumps monitored?
Is monitoring required per 2N .0900?No No No No
Piping components and/or STP were
installed/replaced on or after 11/1/07?
No No No No
Are spills or small weeps evident in
sumps?
No No No No
UST-10B Facility ID:00-0-0000009375
Page 6 of 10 9/15/2022 11:11 AM
Dispenser Sumps Dispenser
#1(Plus)
Dispenser
#2(Regular)
Dispenser
#3(Regular)
Dispenser
#4(Super)
Are single wall piping components located
in containment sump?(If installed after
11/1/07)
UDC Visual Inspection Date
(annually)(UST-22C)
8/9/2022 8/9/2022 8/9/2022 8/9/2022
UDC Visual Inspection Results
(UST-22C)
Pass Pass Pass Pass
Annual containment sump check
completed in accordance with national
standard (e.g.PEI RP 900)?
Yes Yes Yes Yes
Other Sumps Sump#1(Plus)Sump#2(Premi
um)
Sump#3(Regul
ar)
Are containment sumps present?No No No
Installation Date
Sump Manufacturer
If Other (Specify)
Sump Construction Type
Sump Construction Material
If Other (Specify)
Are containment sumps monitored?
Is monitoring required per 2N .0900?No No No
Piping components and/or STP were
installed/replaced on or after 11/1/07?
No No No
Are spills or small weeps evident in sumps?No No No
Are single wall piping components located in
containment sump?(If installed after 11/1/07)
Sump Visual Inspection Date
(annually)(UST-22C)
8/9/2022 8/9/2022 8/9/2022
Sump Visual Inspection Results
(UST-22C)
Pass Pass Pass
Annual containment sump check completed in
accordance with national standard (e.g.PEI RP
900)?
Yes Yes Yes
SITING AND SECONDARY CONTAINMENT
Siting And Sec.Containment-General Tank #1(2
Plus)
Tank #2(3
Premium)
Tank #3(1
Regular)
UST system upgraded with corrosion protection,
spill and overfill before 1/1/91?
N/A N/A N/A
UST system and/or piping are located within siting
and secondary containment areas?
No No No
LEAK DETECTION
General Tank #1(2 Plus)Tank #2(3
Premium)
Tank #3(1
Regular)
DWM notified of leak detection method?Yes Yes Yes
Piping Type
Piping type Pressurized
System
Pressurized
System
Pressurized
System
if other,specify
Suction check type
Type LLD present.MLLD MLLD MLLD
UST-10B Facility ID:00-0-0000009375
Page 7 of 10 9/15/2022 11:11 AM
General Tank #1(2 Plus)Tank #2(3
Premium)
Tank #3(1
Regular)
Tank Release Detection
Primary leak detection method Automatic Tank
Gauging
Automatic Tank
Gauging
Automatic Tank
Gauging
if other,specify
Primary LD install date 12/22/1993 12/22/1993 12/22/1993
Secondary leak detection method
if other,specify
Piping Release Detection
Primary leak detection method Line Tightness
Testing (LTT)
Line Tightness
Testing (LTT)
Line Tightness
Testing (LTT)
if other,specify
Primary LD install date 12/22/1993 12/22/1993 12/22/1993
Secondary leak detection method
if other,specify
Equipment Checks
Last 12 monthly RD equipment checks completed
and all deficiencies corrected (UST-27)?
Yes Yes Yes
if no,select all that apply
Annual RD equipment operability check result
(UST-22B)
Pass Pass
if Fail,select all that apply
Annual RD equipment operability check date
(UST-22B)
8/9/2022 8/9/2022
RD equipment checks completed per national
standard (e.g.PEI RP 900/1200)(UST-22B/27)?
Yes Yes
PIPING LEAK DETECTION
Pressurized Piping Tank #1(2 Plus)Tank #2(3
Premium)
Tank #3(1
Regular)
Last MLLD/ELLD Test Date 8/9/2022 8/9/2022
MLLD/ELLD Test Result Pass Pass
Last LTT Test Date 8/9/2022 8/9/2022
LTT Test Result Pass Pass
Does test result indicate
suspected release?
No No
Number of MLLD/ELLD Types 1 1 1
MLLD/ELLD Equipment Tank #1(2 Plus)LLD
#1
Tank #2(3 Premium)
LLD #1
Tank #3(1 Regular)
LLD #1
MLLD/ELLD Manufacturer/Model V-R/RJ:FX1V (M)V-R/RJ:FX1V (M)V-R/RJ:FX1V (M)
If other,describe
MLLD/ELLD Third Party Certified?Yes Yes Yes
MLLD/ELLD Testers MLLD/ELLD Tester #1
MLLD/ELLD Tester Name Brandon Fipps
MLLD/ELLD Testing Company Name PTS,Inc.
MLLD/ELLD Testing Company Phone Number [phone]
Pressurized Piping LTT LTT #1
LTT Manufacturer/Method AcuRite:Training &Serv
If other,describe
LTT Third Party Certified?Yes
UST-10B Facility ID:00-0-0000009375
Page 8 of 10 9/15/2022 11:11 AM
Pressurized Piping LTT Tester LTT Tester #1
LTT Tester Name Brandon Fipps
LTT Testing Company Name PTS,Inc.
LTT Testing Company Phone Number [phone]
AUTOMATIC TANK GAUGE
ATG Systems ATG #1
ATG Manufacturer/Model V-R:TLS-350 (Mag)
If other,describe
ATG Third Party Certified?Yes
Is ATG console operational?Yes
Tanks #1(2 Plus),#2(3 Premium),#3(1 Regular)
ATG Monthly LD Tank #1(2 Plus)Tank #2(3 Premium)Tank #3(1 Regular)
2022 Aug Pass None Pass
2022 Jul None None None
2022 Jun None None None
2022 May Pass None Pass
2022 Apr None None None
2022 Mar None None None
2022 Feb None None None
2022 Jan None None None
2021 Dec None None None
2021 Nov None None None
2021 Oct Pass None Pass
2021 Sep Pass None Pass
ATG Conclusions
Leak Detection Requirements Met?No
Do the results indicate a suspected
release?
No
Issues 0.2 Test not conducted for 3 or more months (LD1*),Records not
available (RCD5)
INTERSTITIAL MONITORING BEFORE 11/1/07
IM Before 11/07-Monitoring Systems IM Console #1
Console Manufacturer/Model V-R:TLS-350 (Mag)
If other,describe
Tanks
Interstitial Sensors
IM Before 11/07-Spill Buckets Tank #1(2 Plus)Tank #2(3 Premium)
Does Tank have a Remote or Second Fill?No No
Manufacturer/Model of Sensor Visual Gauge:Spill bucket
(Mech)
Visual Gauge:Spill bucket
(Mech)
If other,describe
Monitoring Type
(UST-6B)
Float Gauge (Mech)Float Gauge (Mech)
Sensor third party certified
Sensor Operability Check Date
(annually)(UST-22B)
8/9/2022 8/9/2022
Sensor Operability Check Results
(UST-22B)
Pass Pass
UST-10B Facility ID:00-0-0000009375
Page 9 of 10 9/15/2022 11:11 AM
IM Before 11/07-Spill Bucket Monthly
LD
Tank #1(2 Plus)Tank #2(3 Premium)
2022 Aug None None
2022 Jul None None
2022 Jun None None
2022 May None None
2022 Apr None None
2022 Mar None None
2022 Feb None None
2022 Jan None None
2021 Dec None None
2021 Nov None None
2021 Oct None None
2021 Sep None None
IM Before 11/07-SpillBucket
Conclusions
Leak Detection Requirements Met?No
Do the results indicate a suspected
release?
No
Issues Missing 3 or more monthly LD records (MT6C or LD21-Haz)*
REPAIRS
Repairs
Any Repair Issues?
Issues
Delivery Information Tank #1(2 Plus)Tank #2(3
Premium)
Tank #3(1 Regular)
All deliveries made to permitted tanks Yes Yes Yes
TRANSPORTER/FUEL DELIVERY INFORMATION
Name Address Phone
Eagle Transport
UST-10B Facility ID:00-0-0000009375
Page 10 of 10 9/15/2022 11:11 AM
SITE DIAGRAM 1

NORTH CAROLINA
Environmental Quality

North Carolina Department of Environmental Quality | Division of Waste Management
217 West Jones Street | 1646 Mail Service Center | Raleigh, North Carolina 27699-1646
919.707.8171
ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
MICHAEL SCOTT
Director
September 21, 2022

CERTIFIED MAIL 9414 8118 9956 2927 3712 31
RETURN RECEIPT REQUESTED

Ronald M Gibson, Registered Agent
Gibson Oil & Gas Co Inc
9340 Morgan Street
Laurel Hill, NC 28351

Re: NOTICE OF VIOLATION OF 15A NCAC 2N .0302(UPG10, UPG11), .0402(MT3), .0405(RCD1),
.0406(MT5, MT6), .0501(MT9), .0502(LD1, LD12), .0505(LD18), .0506(RCD5), .0603(RLS7)
Laurinburg Food Mart
609 Produce Market Rd, Laurinburg, NC 28352
Scotland County
Facility ID#: 00-0-0000009375

Dear Ronald M Gibson:

On August 30, 2022, I conducted a compliance inspection at the above-referenced facility. I observed that
underground storage tanks (USTs) at Laurinburg Food Mart are not in compliance with North Carolina UST
regulations (North Carolina Administrative Code [NCAC] 2N "Criteria and Standards Applicable to Underground
Storage Tanks). According to those rules (15A NCAC 2N .0203) Gibson Oil & Gas Co Inc is identified as the owner
and/or operator of UST(s) at Laurinburg Food Mart.

The following violations of the state rules (15A NCAC 2N) were observed on August 30, 2022 at Laurinburg Food
Mart. Following each violation are the actions required to correct the violations:

Violation 1: 15A NCAC 2N .0302 UPG10; Failure to meet the spill prevention requirements of an 'existing tank
system' as required by federal regulation 40 CFR 280.21(d) (as incorporated by 15A NCAC 2N .0302).
Corrective Action(s):
All UST systems installed before December 22, 1988 are defined as 'existing tank systems.' All "existing tank
systems" that are filled by transfers of more than 25 gallons at one time are required to have spill prevention
equipment. Please complete one of the following actions:
1) Repair or empty your spill prevention equipment. If the spill prevention equipment is replaced as part of the repair
then the spill prevention equipment must meet the secondary containment requirements of 15A NCAC 2N .0900 and
must have an integrity test conducted after installation that is documented on a UST-23A form Triennial UST Spill
Bucket Integrity Testing.
Submit a copy of invoices, designs or other documentation of the completed work within 30 days of receipt of this
NOV to the inspector at the address provided. In addition, if spill prevention is added, please submit a UST-8 form,
Notification for Activities Involving USTs, identifying methods (i.e., catchment basin) used along with a UST-23A
form, Triennial UST Spill Bucket Integrity Testing.
Comment: Tank #1 Regular: The most recent UST-23A was not available for review at the time of inspection. It
was revealed the most recent test failed.

Violation 2: 15A NCAC 2N .0302 UPG11; Failure to meet the overfill control requirements of an 'existing tank
system' as required by federal regulation 40 CFR 280.21(d) (as incorporated by 15A NCAC 2N .0302).

North Carolina Department of Environmental Quality | Division of Waste Management
217 West Jones Street | 1646 Mail Service Center | Raleigh, North Carolina 27699-1646
919.707.8171
Corrective Action(s):
All UST systems installed before December 22, 1988 are defined as 'existing tank systems.' All "existing tank
systems" that are filled by transfers of more than 25 gallons at one time are required to have overfill control
equipment. Please complete one of the following actions:
1) The overfill prevention equipment was inspected however the equipment is not installed at the correct height in the
tank or it needs repairing and does not meet the performance standards of 15A NCAC 2N .0301. Provide
documentation, on a UST-22A form, Overfill Prevention Equipment Operability Check, of an operability check
conducted in accordance with the manufacturer's written guidelines, PEI RP 1200 “Recommended Practice for the
Testing and Verification of Spill, Overfill, Leak Detection and Secondary Containment Equipment at UST Facilities”
and the instructions on the UST-22A form.
Please submit a copy of invoices, designs or other documentation, such as a letter signed by the installer or a report
from an equipment contractor, of the completed work within 30 days of receipt of this notice to the inspector at the
address provided. In addition, if overfill control is added, please submit a UST-8 form Notification for Activities
Involving USTs identifying methods (i.e., automatic shut-off device or overfill alarm) used and provide documentation
of an operability check on a UST-22A form, Overfill Prevention Equipment Operability Check.
Comment: Tanks: Regular, Plus, Premium: The most recent UST-22A was not available for review at the time of
inspection. It was revealed the most recent test failed.

Violation 3: 15A NCAC 2N .0402 MT3; Failure to inspect a UST system with an impressed current cathodic
protection system every 60 days as required by federal regulation 40 CFR 280.31(c) (as incorporated by 15A
NCAC 2N .0402).
Corrective Action(s):

1) Please inspect the ampere and volt meters associated with the impressed current cathodic protection system every
60 days and maintain records of the ampere readings noted during your inspection. The results of the last 3 meter
readings must be available for review by a Division of Waste Management UST Section inspector during a compliance
inspection.
Within 30 days of receipt of this notice, submit a copy of the next meter reading to the inspector at the address
provided.
Comment: Tanks: Regular, Plus, Premium: 60-day volt and amp readings were not available for review at the time
of inspection. The UST-27 did not have any volt and amp readings on page 4 of the 2022 form. ,

Violation 4: 15A NCAC 2N .0405 RCD1; Failure to notify or provide the Division of Waste Management UST
Section with records of compliance with leak detection, periodic inspections, testing and/or upgrading
requirements as required by federal regulation 40 CFR 280.34 (as incorporated by 15A NCAC 2N .0405).
Corrective Action(s):
The Division of Waste Management UST Section has noted the following deficiencies with your sites required
notifications or record-keeping:
1) Within 14 days of receipt of this notice, please submit documentation of the spill bucket integrity test (Form UST-
23A), to the inspector at the address provided.
2) Within 14 days of receipt of this notice, please submit documentation of the overfill operability check (Form UST-
22A), to the inspector at the address provided.
Within 14 days of receipt, or other time frame mentioned above, of this notice, please complete and submit the form(s)
checked above and/or provide copies of the records needed to complete the inspection to the inspector at the address
provided. In addition you need to submit a copy of any forms listed above to the address located on the form(s). It is
recommended that you also keep a copy for your records.
Comment: Tanks: Regular, Plus, Premium: The most recent UST-22A was not available for review at the time of
inspection. It was revealed the most recent test failed.,
Tanks: Regular, Plus, Premium: The leak detection records (UST-27) for the plus and premium spill
bucket interstices are not being completed properly. On page 3 of the UST-27, the Tank Information
Sections are not completed to specify which tanks are being monitored. All the boxes are checked pass

North Carolina Department of Environmental Quality | Division of Waste Management
217 West Jones Street | 1646 Mail Service Center | Raleigh, North Carolina 27699-1646
919.707.8171
for the columns of January through September 2022. There should only be a row for the Premium and
Plus spill buckets. The entire top row is checked as passed for January through December 2022. There
should not be any sections completed for the months of September through December 2022.

Violation 5: 15A NCAC 2N .0406 MT5; Failure to check the operability, proper operating condition, and proper
calibration of overfill prevention equipment every three years, in accordance with the manufacturer’s written
guidelines and as required by federal regulation 40 CFR 280.35 (as incorporated by 15A NCAC 2N .0406).
Corrective Action(s):

1) Check overfill prevention equipment for operability, proper operating condition, and proper calibration in
accordance with the manufacturer's written guidelines and PEI RP 1200 “Recommended Practice for the Testing and
Verification of Spill, Overfill, Leak Detection and Secondary Containment Equipment at UST Facilities”. Document
the results on the UST-22A form.
Within 30 days of receipt of this notice, please submit a copy of the results of the annual check and other supporting
documentation of the completed work on form UST-22A, Overfill Prevention Equipment Operability Check, to the
inspector at the address provided.
Comment: Tanks: Regular, Plus, Premium: The most recent UST-22A was not available for review at the time of
inspection. It was revealed the most recent test failed.

Violation 6: 15A NCAC 2N .0406 MT6; Failure to perform a tightness test of a spill bucket every 3 years as required
by federal regulation 40 CFR 280.35 (as incorporated by 15A NCAC 2N .0406).
Corrective Action(s):

1) Conduct a tightness test of the spill bucket for the listed tank(s) in accordance with the manufacturer’s written
guidelines and PEI RP 1200 “Recommended Practice for the Testing and Verification of Spill, Overfill, Leak
Detection and Secondary Containment Equipment at UST Facilities”. Document results on a UST-6D/23A, "Triennial
UST Spill Bucket Integrity Testing", form.
2) No records were provided to show that the interstice of the double wall spill bucket installed prior to 11/1/07 has
been monitored every 30 days. Conduct a tightness test of the spill bucket for the listed tank(s) in accordance with the
manufacturer’s written guidelines and PEI RP 1200 “Recommended Practice for the Testing and Verification of Spill,
Overfill, Leak Detection and Secondary Containment Equipment at UST Facilities”. Document results on a UST-
6D/23A, "Triennial UST Spill Bucket Integrity Testing", form.
Within 30 days of receipt of this notice, please submit the test results on form UST-23A, Triennial UST Spill Bucket
Integrity Testing, to the inspector at the address provided.
Comment: Tank: Regular: The most recent UST-23A was not available for review at the time of inspection. It was
revealed the most recent test failed.,
Tanks: Plus, Premium: The leak detection records (UST-27) for the plus and premium spill bucket
interstices are not being completed. On page 3 of the UST-27, the Tank Information Sections was blank.

Violation 7: 15A NCAC 2N .0501 MT9; Failure to check the operability, proper operating condition, and proper
calibration of leak detection monitoring equipment annually in accordance with the manufacturer's written
guidelines and as required by federal regulation 40 CFR 280.40 (as incorporated by 15A NCAC 2N
.0501).
Corrective Action(s):

1) Check the leak detection equipment for operability, proper operating condition, and proper calibration in accordance
with the manufacturer's written guidelines and PEI RP 1200 “Recommended Practice for the Testing and Verification
of Spill, Overfill, Leak Detection and Secondary Containment Equipment at UST Facilities”.
Within 30 days of receipt of this notice, please submit a copy of the results of the annual check and other supporting
documentation (e.g. alarm reports, invoice, repair records) of the completed work on form UST-22B, Annual Leak

North Carolina Department of Environmental Quality | Division of Waste Management
217 West Jones Street | 1646 Mail Service Center | Raleigh, North Carolina 27699-1646
919.707.8171
Detection Equipment Operability Check, to the inspector at the address provided.
Comment: Tank: Plus: At the time of inspection a UST-22B was not available for review for the plus ATG probe.

Violation 8: 15A NCAC 2N .0502 LD1; Failure to provide leak detection for a regulated tank in accordance with
federal regulation 40 CFR 280.41 (as incorporated by 15A NCAC 2N .0502, 15A NCAC 2N .0301, 15A NCAC
2N .0302 and/or 15A NCAC 2N .0304).
Corrective Action(s):
The Division of Waste Management UST Section has determined that leak detection has not been conducted on a
regulated tank.
1) Single-wall monitored UST: Please immediately conduct a tank tightness test (note: an Automatic Tank Gauge can
not be used to conduct the tank tightness test) on all applicable USTs and submit a copy of your next month's tank
leak detection records.
Please submit, within 30 days of receipt of this notice, a copy of the tank tightness test results (and if applicable,
interstitial space tightness test results) and submit, within 30 days of receipt of this notice, a copy of your leak detection
records (for your chosen leak detection method(s)) for the month following the date of receipt of this notice to the
inspector at the address provided.
Comment: Tanks:Regular, Plus: Tank leak detection records were missing for 8 of the 12 months. ,
Tank #3 Premium: Tank leak detection records were not available for reivew for the premium tank.

Violation 9: 15A NCAC 2N .0502 LD12; Failure to provide leak detection for pressurized and/or gravity piping
systems associated with regulated tanks in accordance with federal regulation 40 CFR 280.41(b)(1)(ii) (as
incorporated by 15A NCAC 2N .0502).

Corrective Action(s):
Leak detection must be provided for pressurized and/or gravity piping systems. Please complete one of the following
requirements:
1) Conduct a line tightness test for each piping system associated with the regulated tank(s). Line tightness testing is
required annually for pressurized and/or gravity piping systems. OR Conduct a line tightness test and apply an
acceptable method of monthly monitoring for each piping system associated with the regulated tank(s). Within 30
days of receipt of this notice, please submit a copy of the line tightness test results to the inspector at the address
provided. If you choose to implement monthly monitoring then you must also submit, within 30 days of receipt of this
notice, copies of the results of your monthly monitoring for the month following the date of receipt of this notice to
the inspector at the address provided.
Comment: Tank #3 Premium: At the time of the inspection, line tightness testing was not available for review.

Violation 10: 15A NCAC 2N .0505 LD18; Failure to conduct an annual test of the operation of an automatic line
leak detector (MLLD or ELLD) of a pressurized piping system associated with a regulated tank in accordance
with federal regulation 40 CFR 280.44(a) (as incorporated by 15A NCAC 2N .0505).
Corrective Action(s):

1) Please conduct a test of the operation of the automatic line leak detector and submit a copy of the results (on a UST-
22B, Annual Leak Detection Equipment Operability Check, or equivalent form) within 30 days of receipt of this
notice to the inspector at the address provided.
Comment: Tank: Premium: At the time of the inspection, line leak detector operability testing was not available
for review.

Violation 11: 15A NCAC 2N .0506 RCD5; Failure to maintain records demonstrating compliance with the leak
detection requirements as required by federal regulation 40 CFR 280.45(b) (as incorporated by 15A NCAC 2N
.0506).

North Carolina Department of Environmental Quality | Division of Waste Management
217 West Jones Street | 1646 Mail Service Center | Raleigh, North Carolina 27699-1646
919.707.8171
Corrective Action(s):

1) The cited rule requires that results of any sampling, testing, or monitoring must be maintained for at least 1 year.
Please maintain the required records and submit to the inspector, at the address provided, a copy of the following: A.
Submit, within 30 days of receipt of this notice, any testing results (tank tightness tests, line tightness tests, etc.); AND
B. Submit, within 30 days of receipt of this notice, a copy of your leak detection records for your chosen method of
leak detection for the month following the date of receipt of this notice.
Comment: Tank Leak Detection: Monthly tank leak detection records are not being maintained.

Violation 12: 15A NCAC 2N .0603 RLS7; Failure to investigate a suspected release in accordance with federal
regulation 40 CFR 280.52 (as incorporated by 15A NCAC 2N .0603) after a failing tightness test of the spill
containment, the presence of fuel in spill containment buckets or the degradation of the spill containment
equipment to the point where that equipment can not reasonably be expected to perform its intended function was
observed.

Corrective Action(s):
Tank owners or operators must investigate a suspected release as directed below.
1) The spill containment bucket failed a tightness test or the condition of the spill containment bucket has deteriorated
such that it may need repairing or replacing. All replaced spill buckets must meet the secondary containment
requirements of 15A NCAC 2N .0900. You must complete the actions listed below.
Conduct a tightness test (if one has not already been completed) of the existing spill containment bucket(s) integrity
(prior to repair/replacement) in accordance with the manufacturer's recommendations* or a code of practice developed
by a nationally recognized association. If a testing standard is not available then you must fill the spill containment
bucket(s) with clean water to within 1.5 inches of the top of the spill bucket; mark the water level; wait a minimum of
1 hour and re-check the level. A spill containment bucket fails the tightness test if there has been any change in level.
Submit a copy of the test results to the inspector at the address provided. If any spill containment bucket fails the
tightness test, you must complete all of the following tasks: (a) Conduct a site check around the spill containment
bucket for the tanks listed above in accordance with 40 CFR 280.52(b) (as incorporated by 15A NCAC 2N .0603)
using the sampling protocol and methodology of the most recent version of the UST Section Guidelines for Site
Checks, Tank Closure, and Initial Response and Abatement and submit, within 30 days of receipt of this notice, a site
check report or initial abatement report (whichever is applicable) to the inspector at the address provided; AND (b)
Repair or replace the spill containment bucket and test the tightness of the spill containment bucket in accordance with
the manufacturer's recommendations, a code of practice developed by a nationally recognized association, or the
alternate instructions listed above if no standard is available. All replaced spill buckets must meet the secondary
containment requirements of 15A NCAC 2N .0900. Within 30 days of receipt of this notice, unless noted differently
above, submit a UST-17B, UST Suspected Release 7 Day Notice, with the results and any supporting information for
all equipment repairs, equipment replacements, tightness test(s), and site check as required in the above sections to
the inspector at the address provided. * Proper disposal of liquids in accordance with State and Federal requirements
is required. See the attached document Recommended ways to dispose of small quantities of petroleum and
petroleum/water mixtures for some suggested methods.
Comment: Tank: Regular: The most recent UST-22A was not available for review at the time of inspection. It was
revealed the most recent test failed.

Notice of Deficiency:

Deficiency 1: NCGS 143-215.94NN-SS OPTR4; Failure to maintain compliance with UST regulations which
requires Primary Operator retraining as required by NCGS 143-215.94NN - 143.215.94SS.
Corrective Action(s):
Please perform the following corrective action:
1) Within 30 days of receipt of this notice, the Primary Operator designated for this facility must go to the following
website http://tankschool.nc.gov and take the NC DEQ on-line course for retraining. Retraining as a Primary
Operator must be completed and a Primary Operator training certificate achieved within 30 days of receipt of this

North Carolina Department of Environmental Quality | Division of Waste Management
217 West Jones Street | 1646 Mail Service Center | Raleigh, North Carolina 27699-1646
919.707.8171
notice.

Comment: Due to the violations noted at the time of inspection, the primary operator must be re-trained by
completing tank school online.

Corrective actions must be completed and reported to the inspector at the address provided within 30 days of receipt
of this notice, unless otherwise noted in one of the corrective actions listed above. Assessment of civil penalties may
be recommended for violations described in this NOV, as well as, operating permit revocation/denial unless the
violations are corrected. If Gibson Oil & Gas Co Inc believes that the inspection findings are in error, or if Gibson
Oil & Gas Co Inc has any questions pertaining to this NOV and/or corrective actions please have it contact me at
[phone] or [e-mail].

Sincerely,
Gina Williams, Environmental Specialist
Division of Waste Management, NC DEQ
D

Enclosures: UST-10B (UST Inspection Checklist)

cc: Michael Phelps w/ Enclosures (electronic)
Files (electronic)
UST-6D/23A
Page 1
Triennial UST Spill Bucket Integrity Testing
(Hydrostatic/Vacuum Test)
Ø If any periodic test fails, a suspected release report must be submitted on a UST-17A form, UST Suspected Release 24 Hour Notice. The suspected
release must be investigated, in accordance with 15A NCAC 2N .0603, and defective equipment repaired or replaced in accordance with 15A NCAC 2N
.0404/.0900. Results of the investigation must be submitted on a UST-17B form, UST Suspected Release 7 Day Notice.
Ø The primary containment and interstitial space of the spill bucket shall be tested in accordance with the manufacturer’s written guidelines, PEI/RP100
“Recommended Practices for Installation of Underground Liquid Storage Systems” and/or PEI/RP1200 “Recommended Practices for the Testing and
Verification of Spill, Overfill, Leak Detection and Secondary Containment Equipment at UST Facilities.”
Ø The primary and secondary walls are both considered to be tested at the same time if vacuum is used to test the interstice.
UST FACILITY
Owner / Operator Name
GIBSON OIL AND GAS CO.
Facility Name
LAURINBURG FOOD MART
Facility ID#:
00-0-0000009375
Facility Street Address
609 PRODUCE MARKET RD.
Facility City
LAURINBURG
County
SCOTLAND
TESTING CONTRACTOR INFORMATION
Company Name
PIEDMONT PUMP AND TANK, LLC
Phone
919-697-9652
E-mail Address
[e-mail]
I certify, under penalty of law, that the testing data provided on this form documents the UST system equipment was tested in accordance with the manufacturer’s guidelines and the applicable national industry standards listed in 15A NCAC 2N .406 and/or 15A NCAC 2N .0900.
DEREK TURNER 01/06/2023
Print Name of person conducting test Signature of person conducting test Test Date

Identify Spill Bucket (By Tank
Number, Stored Product, etc.) Tank #1 Tank # Tank # Tank # Tank #
Tank Size 8,000
Product RUL
Indicate units for all measurements
Bucket Manufacturer/Model OPW 1C-3112P
Bucket Depth 12"
Construction SW DW SW DW SW DW SW DW SW DW
Bucket Installation Type
Direct Bury
Direct Bury w/Liner
Containment
sump
Direct Bury
Direct Bury w/Liner
Containment
sump
Direct Bury
Direct Bury w/Liner
Containment
sump
Direct Bury
Direct Bury w/Liner
Containment
sump
Direct Bury
Direct Bury w/Liner
Containment
sump
Test Type Hydrostatic
Vacuum
Hydrostatic
Vacuum
Hydrostatic
Vacuum
Hydrostatic
Vacuum
Hydrostatic
Vacuum
Liquid and debris removed from
spill bucket? Yes No Yes No Yes No Yes No Yes No
Visual inspection (No cracks,
loose parts or separation of the
bucket from fill pipe.)
Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Tank riser cap included in test? Yes No
N/A
Yes No
N/A
Yes No
N/A
Yes No
N/A
Yes No
N/A
Drain valve included in test? Yes No
N/A
Yes No
N/A
Yes No
N/A
Yes No
N/A
Yes No
N/A
Wait time between applying
vacuum/water and start of test 5 MIN
Primary Section Test Hydrostatic: Water level must be within 1.5 inches of top of bucket Vacuum: Apply vacuum of 30 inches WC
Begin I End Test Time I I I I I
Begin I End Reading I I I I I
Secondary Interstice Test Vacuum: Apply vacuum of 15 inches WC Gauge range (with units):
Begin I End Test Time 14:22 I 14:28 I I I I
Begin I End Reading 15.25" WC I 15.25"
WC I I I I
Pass/fail criteria: Must pass visual inspection. Pass if: Hydrostatic: Water level drop of less than 1/8 inch in 1 hour; Vacuum single-walled
only: Maintain at least 26 inches water column for 1 minute; Vacuum double-walled: Maintain at least 12 inches water column for 1 minute
Test Results Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Comments – (include information on repairs made prior to testing, and recommended follow-up for failed tests)

Date next Spill Bucket integrity test due (required every 3 years) 01/06/2026
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION
1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE [phone] FAX [phone] http://www.wastenotnc.org/ 11/2022

UST-6D/23A
Page 2
Triennial UST Spill Bucket Integrity Testing
(Dri-sump® Test)
Ø If any periodic test fails, a suspected release report must be submitted on a UST-17A form, UST Suspected Release 24 Hour Notice. The suspected
release must be investigated, in accordance with 15A NCAC 2N .0603, and defective equipment repaired or replaced in accordance with 15A NCAC 2N
.0404/.0900. Results of the investigation must be submitted on a UST-17B form, UST Suspected Release 7 Day Notice.
Ø Single wall spill buckets not located within a containment sump can use the Dri-sump® testing method. If a spill bucket is located within a containment
sump then a hydrostatic or vacuum test would need to be performed on the spill bucket. If the spill bucket is required to be double-walled, then the Dri-
sump® testing method can be used to test the containment sump. Complete page 3 of the UST-23B form to document those results.
UST FACILITY
Owner / Operator Name

Facility Name

Facility ID#:

Facility Street Address Facility City County
TESTING CONTRACTOR INFORMATION
Company Name

Phone

E-mail Address

I certify, under penalty of law, that the testing data provided on this form documents the UST system equipment was tested in accordance with the manufacturer’s guidelines and the applicable national industry standards listed in 15A NCAC 2N .0406 and/or 15A NCAC 2N .0900, or another
method approved by NC DEQ.

Print Name of person conducting test Signature of person conducting test Test Date
Tester Certification #: Equipment Certification #:
Tester Certification Expiration: Equipment Certification Expiration:

Identify Spill Bucket (By Tank
Number, Stored Product, etc.) Tank # Tank # Tank # Tank # Tank #
Tank Size
Product
Bucket Manufacturer/Model
Construction SW DW SW DW SW DW SW DW SW DW
Bucket Installation Type Direct Bury
Direct Bury w/Liner
Direct Bury
Direct Bury w/Liner
Direct Bury
Direct Bury w/Liner
Direct Bury
Direct Bury w/Liner
Direct Bury
Direct Bury w/Liner
Liquid and debris removed from spill
bucket? Yes No Yes No Yes No Yes No Yes No
Visual inspection (No cracks, loose
parts or separation of the bucket
from fill pipe.)
Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
VST Communication (Enter VST
number) VST #: VST #: VST #: VST #: VST #:
Closed Hose (C) (in WC)
Open Hose (O) (in WC)
VST Connected (V) (in WC)
VST Communication Passes when: C > O and C > V and V ≥ O
Test length in seconds
(DW Primary wall or SW)
Laser Verification
(DW Primary wall or SW)
Dot (Pass)
Line (Fail)
Dot (Pass)
Line (Fail)
Dot (Pass)
Line (Fail)
Dot (Pass)
Line (Fail)
Dot (Pass)
Line (Fail)
Test length in seconds
(Secondary wall, if DW)
Laser Verification
(Secondary wall, if DW)
Dot (Pass)
Line (Fail)
Dot (Pass)
Line (Fail)
Dot (Pass)
Line (Fail)
Dot (Pass)
Line (Fail)
Dot (Pass)
Line (Fail)
Pass/Fail criteria: Must pass visual inspection. Laser result must be a laser-dot (pass). If the first test fails, then conduct a second test entering results in
another column. Test is not valid if liquid or debris was not removed from spill bucket. VST location map must be attached to this report.
Final Test Result Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Comments – (include information on repairs made prior to testing, and recommended follow-up for failed tests)

Date next Spill Bucket integrity test due (required every 3 years)
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION
1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE [phone] FAX [phone] http://www.wastenotnc.org 11/2022

UST-6D/23A
Page 3
Triennial UST Spill Bucket Integrity Testing
(DPleak® Test)
Ø If any periodic test fails, a suspected release report must be submitted on a UST-17A form, UST Suspected Release 24 Hour Notice. The suspected
release must be investigated, in accordance with 15A NCAC 2N .0603, and defective equipment repaired or replaced in accordance with 15A NCAC 2N
.0404/.0900. Results of the investigation must be submitted on a UST-17B form, UST Suspected Release 7 Day Notice.
Ø Single wall spill buckets not located within a containment sump can use the DPleak® testing method. If a spill bucket is located within a containment
sump and is required to be double-walled, then the DPleak® testing method can be used to also test the containment sump. Complete page 4 of the
UST-23B form to document those results.
UST FACILITY
Owner / Operator Name

Facility Name

Facility ID#:

Facility Street Address

Facility City

County

TESTING CONTRACTOR INFORMATION
Company Name

Phone

E-mail Address

I certify, under penalty of law, that the testing data provided on this form documents the UST system equipment was tested in accordance with the
manufacturer’s guidelines and the applicable national industry standards listed in 15A NCAC 2N .0406 and/or 15A NCAC 2N .0900, or another
method approved by NC DEQ.

Print Name of person conducting test Signature of person conducting test Test Date
Tester Certification #:

Identify Spill Bucket (By Tank
Number, Stored Product, etc.) Tank # Tank # Tank # Tank # Tank #
Tank Size
Product
Bucket Manufacturer/Model
Construction SW DW SW DW SW DW SW DW SW DW
Bucket Installation Type Direct Bury
Direct Bury w/Liner
Direct Bury
Direct Bury w/Liner
Direct Bury
Direct Bury w/Liner
Direct Bury
Direct Bury w/Liner
Direct Bury
Direct Bury w/Liner
Liquid and debris removed from spill
bucket? Yes No Yes No Yes No Yes No Yes No
Visual inspection (No cracks, loose
parts or separation of the bucket
from fill pipe.)
Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Wall Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Drain Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Bottom of Riser Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Top of Riser Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Swivel Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Cap Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass Fail
N/A
Pass/Fail criteria: Must pass visual inspection. Test is not valid if liquid or debris was not removed from spill bucket. No areas of spill bucket that fail.
LDT test report with addendums attached Yes No
Final Test Result Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Comments – (include information on repairs made prior to testing, and recommended follow-up for failed tests)

Date next Spill Bucket integrity test due (required every 3 years)
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION
1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE [phone] FAX [phone] http://www.wastenotnc.org 11/2022

UST-22B
Page 1
Annual Leak Detection Equipment Operability Check
(Interstitial Sensors)
Inspect the leak detection equipment in accordance with manufacturer guidelines and PEI RP 1200, “Recommended Practices for the Testing and Verification of Spill,
Overfill, Leak Detection, and Secondary Containment Equipment at UST Facilities”. If the manufacturer’s instructions do not require a condition to be implemented that
triggers an alarm, then you must also trigger an alarm condition. Print the alarm reports triggered during the operability check and attach to this form.
If the equipment manufacturer (e.g., Veeder Root) requires a training certification to conduct operability checks of their equipment then you must be certified.
Results must be maintained for at least one year at the UST site or the tank owner or operator’s place of business and be readily available for inspection.
UST FACILITY
Owner / Operator Name

Facility Name

Facility ID#:

Facility Street Address

Facility City

County

CONTRACTOR/PERSON CONDUCTING INSPECTIONS
Company Name

Phone

Email Address

I certify, under penalty of law, that the testing data provided on this form documents the UST system equipment was checked in accordance with the
manufacturer’s guidelines and the applicable national industry standards listed in 15A NCAC 2N .407/.0501 and/or 15A NCAC 2N .0900.

Print Name of person conducting inspection Signature of person conducting inspection Inspection Date
Sensor Location:

Enter Location #/Description:
Dispenser
Spill Bucket
Tank Interstice
Tank Top and
Other Sumps
#:
Dispenser
Spill Bucket
Tank Interstice
Tank Top and
Other Sumps
#:
Dispenser
Spill Bucket
Tank Interstice
Tank Top and
Other Sumps
#:
Dispenser
Spill Bucket
Tank Interstice
Tank Top and
Other Sumps
#:
Dispenser
Spill Bucket
Tank Interstice
Tank Top and
Other Sumps
#:
Tank Volume (gallons):
Product:
Sensor Manufacturer/Model:
Type of Sensor
Discriminating
Non-
discriminating
Discriminating
Non-
discriminating
Discriminating
Non-
discriminating
Discriminating
Non-
discriminating
Discriminating
Non-
discriminating
Is Sensor Position sensitive? (N/A if
No and Pos. Sens. not required)
Yes No
N/A
Yes No
N/A
Yes No
N/A
Yes No
N/A
Yes No
N/A
Test Liquid Water
Product
Water
Product
Water
Product
Water
Product
Water
Product
Is the ATG console clear of any
active or recurring warnings or
alarms regarding the leak sensor? If
the sensor is in alarm and
functioning, indicate why.
Yes No Yes No Yes No Yes No Yes No
Is the sensor alarm circuit
operational? Yes No Yes No Yes No Yes No Yes No
Has sensor been inspected and in
good operating condition? Yes No Yes No Yes No Yes No Yes No
If Position Sensitive, does sensor
alarm when raised off bottom?
Yes No
N/A
Yes No
N/A
Yes No
N/A
Yes No
N/A
Yes No
N/A
When placed in the test liquid, does
the sensor trigger an alarm?
(If sensor cannot be removed, e.g.,
Emco Spill bucket sensor then N/R)
Yes No
N/R
Yes No
N/R
Yes No
N/R
Yes No
N/R
Yes No
N/R
When an alarm is triggered, is the
sensor properly identified on the ATG
console? Yes No Yes No Yes No Yes No Yes No
Sensor mounted at the lowest point
of interstice (e.g., within 2 inches of
containment sump bottom) (Liquid
detecting float sensors only)
Yes No
N/A
Yes No
N/A
Yes No
N/A
Yes No
N/A
Yes No
N/A
Alarm report attached? Yes No Yes No Yes No Yes No Yes No
Any “No” answer indicates the sensor fails the test.
Test Results Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION
1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE [phone] FAX [phone] http://www.wastenotnc.org/ 11/2022

UST-22B
Page 2
Annual Leak Detection Equipment Operability Check
(Automatic Tank Gauge / Spill Bucket Visual Gauge)
Inspect the leak detection equipment in accordance with manufacturer guidelines and PEI RP 1200, “Recommended Practices for the Testing and Verification of Spill, Overfill, Leak Detection, and Secondary Containment Equipment at UST Facilities”.
If the equipment manufacturer (e.g., Veeder Root) requires a training certification to conduct operability checks of their equipment then you must be certified.
Results must be maintained for at least one year at the UST site or the tank owner or operator’s place of business and be readily available for inspection.
UST FACILITY
Owner / Operator Name
GIBSON OIL AND GAS CO.
Facility Name
LAURINBURG FOOD MART
Facility ID#:
00-0-0000009375
Facility Street Address
609 PRODUCE MARKET RD.
Facility City
LAURINBURG
County
SCOTLAND
CONTRACTOR/PERSON CONDUCTING INSPECTIONS
Company Name
PIEDMONT PUMP AND TANK, LLC
Phone
919-697-9652
Email Address
[e-mail]
I certify, under penalty of law, that the testing data provided on this form documents the UST system equipment was checked in accordance with the manufacturer’s guidelines and the applicable national industry standards listed in 15A NCAC 2N .0407/.0501.
DEREK TURNER 01/06/2023
Print Name of person conducting inspection Signature of person conducting inspection Inspection Date
Tank Volume (gallons): 8,000
Tank Diameter (inches): 96"
Product: RUL
Automatic Tank Gauge (ATG) N/A Note: If the facility is using the ATG to obtain data for SIR then the
ATG operability check must be completed.
ATG Brand and Model
1. Using tank stick measure fuel level. Stick value agrees
with Fuel level displayed on console? Yes No Yes No Yes No Yes No
2. Using tank stick measure water level. Stick value agrees
with Water level displayed on console? Yes No Yes No Yes No Yes No
3. After removing the ATG probe from the tank, has it been
inspected, and any damaged or missing parts replaced? Yes No Yes No Yes No Yes No
4. Franklin Fueling INCON ATGs: Volume Qualifier is 14% or
greater? (Attach printout) (Skip question for other ATGs) Yes No Yes No Yes No Yes No
Magnetostrictive Probes
5. Float moves freely on the stem without binding? Yes No Yes No Yes No Yes No
6. Inch level (to nearest 1/8 inch) from bottom of stem when
90% alarm is triggered.
7. Inch level at which the overfill alarm activates corresponds
with value programmed in the gauge? Yes No Yes No Yes No Yes No
8. Inch level (to nearest 1/8 inch) from bottom when the water float first triggers an alarm or warning.
9. Inch level at which the water float alarm activates
corresponds with value programmed in the gauge? Yes No Yes No Yes No Yes No
10. Alarm reports attached? Yes No Yes No Yes No Yes No
Capacitance Probes
11. Initiated diagnostic check of probes from console? Yes No Yes No Yes No Yes No
12. Diagnostic check does not show any open or shorted
segments in measurement section of probe? (Attach
diagnostic report to form)
Yes No Yes No Yes No Yes No
If any answers in Lines 1, 2, 3 (all ATGs) or 4 (INCON); 5, 7, 9 or 10 (for Mag Probes); 11 or 12 (for Cap Probes) are “No”, the system has failed the test.
Test Results Pass Fail Pass Fail Pass Fail Pass Fail
Spill Bucket Interstice Visual Gauge N/A
Gauge manufacturer OPW
Gauge removed and visually inspected, and no damage
noted? Yes No Yes No Yes No Yes No
O-ring/seals on entry fitting of gauge are present and not
damaged? Yes No Yes No Yes No Yes No
Float mechanism moves freely up and down? Yes No Yes No Yes No Yes No
Indicator arrow rotates when float moved up and down
(Franklin Fueling, Fairfield Ind, and OPW) or Indicator shows
red, “TEST”, when float in up position and green, “Ok” when
float in down position (Emco Wheaton)?
Yes No Yes No Yes No Yes No
Test Results (Any “No” answer indicates the equipment fails.) Pass Fail Pass Fail Pass Fail Pass Fail
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION
1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE [phone] FAX [phone] http://www.wastenotnc.org 11/2022

UST-22B
Page 3
Annual Leak Detection Equipment Operability Check
(Mechanical and Electronic Line Leak Detectors)
UST FACILITY
Owner / Operator Name

Facility Name

Facility ID#:

Facility Street Address

Facility City

County

CONTRACTOR/PERSON CONDUCTING INSPECTIONS
Company Name

Phone

Email Address

I certify, under penalty of law, that the testing data provided on this form documents the UST system equipment was checked in accordance with
the manufacturer’s guidelines and the applicable national industry standards listed in 15A NCAC 2N .0407/.0501.

Print Name of person conducting inspection Signature of person conducting inspection Inspection Date
Tank #:
Tank Size:
Product:
Leak Detector Manufacturer
Leak Detector Model
Type of Leak Detector MLLD
ELLD
MLLD
ELLD
MLLD
ELLD
MLLD
ELLD
MLLD
ELLD
MLLD (ALL PRESSURE MEASUREMENTS ARE MADE IN PSIG)
STP Full Operating Pressure
Check Valve Holding Pressure
Line Resiliency (ml) (line bleed back
volume as measured from check
valve holding pressure to 0 psig)

Step Through Time in Seconds
(time the MLLD hesitates at
metering pressure before going to
full operating pressure as measured
from 0 psig with no leak induced on
the line)

Metering Pressure (STP pressure
when simulated leak rate, 3 gph at
10 psig)

Opening Time in Seconds (the time
the MLLD opens to allow full
pressure after simulated leak is
stopped)

Does the STP pressure remain at or
below the metering pressure for at
least 60 seconds when the
simulated leak is induced?
Yes No Yes No Yes No Yes No Yes No
Does the leak detector reset (trip)
when the line pressure is bled off to
zero psig?
Yes No Yes No Yes No Yes No Yes No
Does the STP properly cycle on/off
under normal fuel system operation
conditions?
Yes No Yes No Yes No Yes No Yes No
A “No” answer to any of the above questions indicates the MLLD fails the test.
ELLD (ALL PRESSURE MEASUREMENTS ARE MADE IN PSIG)
STP Full Operating Pressure
How many test cycles are observed
before alarm/shutdown occurs?
Does the simulated leak cause an
alarm? (If “No” then leak detector
fails)
Yes No Yes No Yes No Yes No Yes No
Does the simulated leak cause an
STP shutdown?
Yes No
N/A
Yes No
N/A
Yes No
N/A
Yes No
N/A
Yes No
N/A
ELLD alarm reports attached?
(If “No” then leak detector fails) Yes No Yes No Yes No Yes No Yes No
Test Results Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION
1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE [phone] FAX [phone] http://www.wastenotnc.org 11/2022

UST-22B
Page 4
Annual Leak Detection Equipment Operability Check
(Groundwater/Vapor Monitoring and Handheld LD Equipment)
Inspect the leak detection equipment in accordance with manufacturer guidelines and PEI RP 1200, “Recommended Practices for the Testing and Verification of Spill,
Overfill, Leak Detection, and Secondary Containment Equipment at UST Facilities”.
Results must be maintained for at least one year at the UST site or the tank owner or operator’s place of business and be readily available for inspection.
UST FACILITY
Owner / Operator Name

Facility Name

Facility ID#:

Facility Street Address

Facility City

County

CONTRACTOR/PERSON CONDUCTING INSPECTIONS
Company Name

Phone

Email Address

I certify, under penalty of law, that the testing data provided on this form documents the UST system equipment was checked in accordance with
the manufacturer’s guidelines and the applicable national industry standards listed in 15A NCAC 2N .0407/.0501.

Print Name of person conducting inspection Signature of person conducting inspection Inspection Date
Tank #:
Tank Size:
Product:
N/A Yes No Yes No Yes No Yes No Yes No
Ground-
water /
Vapor
Monitoring
Handheld monitoring
equipment operable and
serviceable?

Electronic monitoring
equipment operable and
calibrated?

Equipment alarm and battery backup
functional?

Monitoring equipment configuration checked
and within specifications?

Probes and sensors have
no residual buildup?
Floats move freely, the
shaft is not damaged, and
cables are free of
kinks/breaks?

Alarm tested and
operable?
Any “No” answer indicates the Groundwater or Vapor monitoring equipment fails the test.
Test Results Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Tank Gauge Stick (Statistical
Inventory Reconciliation and Manual
Tank Gauging)
N/A Note: If the facility is using the ATG to obtain data for SIR then the ATG
operability check must be completed.
Tank gauge stick can be clearly read, is not warped
or broken? Yes No Yes No Yes No Yes No Yes No
Tank gauge stick has plastic button on bottom of
stick? Yes No Yes No Yes No Yes No Yes No
Vacuum/Pressure Monitoring
Equipment N/A
Vacuum/Pressure gauge is functional and
calibration has been checked? Yes No Yes No Yes No Yes No Yes No
Any “No” answer indicates the Hand-held LD or Vacuum/Pressure monitoring equipment fails the test.
Test Results Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Comments and explanation of failing results and other problems noted during inspection:

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION
1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE [phone] FAX [phone] http://www.wastenotnc.org 11/2022

Appendix B
UST-61 Form

UST-61 24-Hour Release and UST Leak Reporting Form.
For Releases
in NC
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
suspected release
(DWM USE ONLY) Incident # ________ Risk (H,I,L,U)_______ Received On ________ Received By ________
Reported by (circle one): Phone, Fax or Report Region _______
Suspected Contamination? (Y/N) ________ Confirmed GW Contamination? (Y/N) ______ Confirmed Soil Contamination ?(Y/N) ______
Samples Taken?(Y/N) ______ Free Product? (Y/N) _____ If Yes, State Greatest Thickness ______________
Facility ID Number ______________ Date Leak Discovered ___________ Comm/Non-Commercial? ________
Reg/Non-regulated? _____________
INCIDENT DESCRIPTION
Incident Name:
Address: County:
City/Town: Zip Code: Regional Office (circle one): Asheville, Mooresville, Fayetteville, Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): Longitude (decimal degrees) : Obtained by:
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)  GPS
 Topographic map
 GIS Address matching
 Other
 Unknown
Describe location:

HOW RELEASE WAS DISCOVERED (Release Code)
(Check one)
 Release Detection Equipment or Methods
 During UST Closure/Removal
 Property Transfer
 Visual/Odor
 Water in Tank
 Water Supply Well Contamination
 Groundwater Contamination
 Surface Water Contamination
 Other (specify) _______________

SOURCE OF CONTAMINATION
Source of Release (Check primary source) Cause of Release (Check primary cause) Type of Release (Check one) Product Type Released (Check primary product type released)

 Tank
 Piping
 Dispenser
 Submersible Turbine Pump
 Delivery Problem
 Spill Bucket
 Other
 Unknown
Definitions presented on reverse

 Spill
 Overfill
 Corrosion
 Physical/Mechanical
Damage
 Install Problem
 Other
 Unknown
Definitions presented on reverse

 Petroleum
 Non-Petroleum
 Both
Location
(Check one)
 Facility
 Residence
 Other

 Gasoline/ Diesel/
Kerosene
 Heating Oil
 Other Petroleum
Products
 Metals
 Other Inorganics
 Other Organics

 Diesel/Veg. Oil
Blend
 Vegetable Oil 100%
 E10 – E20
 E21 – E84
 E85 – E99
 Ethanol 100%
 E01 – E09
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
Point of Contact Address
City State Zip Code Telephone Number
UST SYSTEM OPERATOR
UST Operator/Company Address
City State Zip Code Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner Address
City State Zip Code Telephone Number
Draw Sketch of Area (showing two major road intersections) or Attach Map
Person Reporting Incident Company Telephone Number
Title Address Date
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
UST-10B Facility ID:00-0-0000009375
Page 10 of 10 9/15/2022 11:11 AM
SITE DIAGRAM 1

Appendix C
UVF Analytical Report

3502 Hayes Road • Monroe, North Carolina 28110
113 West Firetower Road, Suite G • Winterville, North Carolina 28590
Phone [phone] • [phone] • Fax [phone]
Engineering Certification: C-2727 • Geology Certification: C-127
UVF Trilogy Analytical Report

Samples Collected: January 4, 2023
Samples Analyzed: January 6, 2023
Site Name: Laurinburg Food Mart
Site Address: 1201 Produce Market Rd. Laurinburg, NC
GRI Project Number: 4098

January 6, 2023

Kyle Perry
Operator

Technical Procedures
Sample Collection and Handling
Soil samples may be collected using any acceptable procedure. Sampler must use a clean pair of nitrile
gloves for each sample collected. The sample will be placed in a clean, sealable bag (ziplock). Once
collected, the sample must be analyzed immediately or placed on ice. The sample may be kept on ice for
up to 48 hours prior to UVF analyses. If the sample cannot be analyzed within 48 hours, the sample may
be extracted and kept at 4 degrees C for up to 14 days. Proper chain-of-custody procedures must be
followed.
Calibration
The UVF Trilogy has standard calibrations stored for the following analysis:
 GRO
 DRO
 Total PAH
 Target PAH
 Heavy PAH
Prior to use, calibration standards are used to perform a 5-point verification on the factory stored
calibrations for GRO and DRO. The calibration standards used are as follows:
GRO
 0.5 ppm
 1 ppm
 3 ppm
 5 ppm
 10 ppm
DRO
 0.1 ppm
 0.5 ppm
 1 ppm
 3 ppm
 5 ppm
Operation
Sample Extraction
 5mg of soil are weighed into a clean extraction jar
 Methanol is added to the extraction jar to create a 2x or 4x dilution
o 2x Dilution: 10 mL of methanol
o 4x Dilution: 20 mL of methanol
 The extraction jar is shaken for several minutes to thoroughly mix the soil with solvent
(methanol)
 The mixture is allowed to settle for several minutes
 A clean syringe is used to draw liquid from the extraction jar
 A clean filter is attached to the end of the syringe and the liquid dispensed through the filter
into a clean test tube
 This liquid is referred to as the extraction
 Please note that any samples extracted and/or analyzed offsite require a Chain of Custody
documenting the collection, extraction and custody of the sample(s)

Technical Procedures
Dilution Preparation
 An adjustable micropipette is used to precisely measure out the amount of extract needed for
the dilution
 The measured out amount of the extract is added to a clean test tube and methanol is added to
dilute the extract. Examples of dilutions are shown below:

Extract Amount
500 μL
200 μL
100 μL
50 μL
25 μL

Add Solvent to the
5 mL line
5 mL line
5 mL line
5 mL line
5 mL line
2x Extract
Dilution Factor
20x
50x
100x
200x
400x
4x Extract
Dilution Factor
40x
100x
200x
400x
800x

Sample Analyzation
 The dilution is shaken to thoroughly mix, then poured into a clean glass cuvette
 The desired module is inserted into the UVF Trilogy and the corresponding factory calibration is
selected
 “Measure Fluorescence” is pressed on the touchscreen and the reading is recorded
 The reading should be between the concentrations of the calibration standards (GRO: 0.5-10
ppm; DRO 0.1-5 ppm)
o Reading below the calibration standard range are recorded as below the detection limit
 Detection Limit = (lower range of calibration standards range) x dilution factor
(i.e. a GRO sample with a 100x dilution factor has a detection limit of 50 ppm)
o Readings above the calibration standard range should be further diluted and reanalyzed
o Negative readings are an indication of quenching (see below)
 The reading is multiplied by the dilution factor to calculate the final concentration
 Check suspected contaminated samples for quenching by running additional dilutions
o According to the siteLAB Quick Reference Guide:
“Quenching” can occur when the detector is swamped by too many hydrocarbons or
organic interferences, producing low or negative concentrations. Test the sample at
multiple dilutions to confirm results are linear and accurate.”
QA/QC
Calibration
 The UVF Trilogy will be calibrated daily prior to use
 The calibration results will be saved and entered into the calibration log
Method Blank
 A method blank of methanol will be analyzed following calibration and following the last sample
analyzed for each day
Duplicates
 One duplicate will be analyzed for every 20 samples
 The duplicate will be prepared from the extract of the sample and diluted to the same factor as
the sample analyzed
Project Name:Date Collected:
Project Number:Date Analysed:
Project Manager:Operator:
Sample ID Matrix Dilution
Factor x
GRO
Output
(ppm)
=GRO Value
(mg/Kg)
Dilution
Factor x
DRO
Output
(ppm)
=DRO Value
(mg/Kg)
Reg. Spill Bucket (2')Soil 100 2.07 207 ---------
UVF Analytical Report
siteLAB UVF Trilogy
1/6/2023
1/1/2023
Kyle Perry
Laurinburg Food Mart
4098
William Regenthal
Site:
Laurinburg Food Mart
Report Date:
1/6/2023
Page:
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