MO-88904_96938_CA_UST-62_20230116

UST-62 24-Hour Notification of Discharge Form
For Non-UST This form should be completed and submitted to the UST Section’s regional office following a known or suspected release of
Releases of petroleum from a source other than an underground storage tank. This form is required to be submitted within 24 hours of
Petroleum in NC discovery of a known or suspected petroleum release

(DWM USE ONLY)
Incident # Priority Rank (H,I,L,U)
Received (time/date)
Received by Region
Reported by (circle one): Phone, Fax or Report

Suspected Contamination? (Y/N) Y
Confirmed GW Contamination? (Y/N) N
Confirmed Soil Contamination ?(Y/N) Y
Samples taken?(Y/N) Y Free product? (Y/N) N
If Yes(free product), state greatest thickness: NA feet

Release discovered
(time/date):
10/6/2022
INCIDENT DESCRIPTION
Incident Name: 11611 Reames Road – Pavement Sealer Spill
Address (street number/name): 11611 Reames Road County: Mecklenburg
City/Town: Charlotte Zip Code: 28269 Regional Office (circle one): Asheville, Mooresville, Fayetteville,
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): 35.3466 Longitude (decimal degrees) :-80.8257 Obtained by:
D GPS
X Electronic topographic map
D GIS Address matching
D Other
D Unknown
Describe location: Equipment
parking lot at site.
Describe suspected or confirmed release (nature of release, time/date of release, quantity of release, amount of free
product): A suspected historical releases of pavement sealer from AST piping and connections to adjacent equipment
storage agea.

Describe initial response/abatement (time/date release stopped, cleanup begun/completed, quantity of product
soil removed, confirmation sampling):
A suspected historical release investigation was undertaken and soil samples were collected and analyzed from
test pits excavated along drainage pathway to determine nature and extent of same.
Describe impacted receptors:
Shallow (<4-feet deep) soils with lab data showing no impacts below 4-feet , see attached Table 1
HOW RELEASE WAS DISCOVERED (Release Code)
(Check one)
D Observation of Release at Occurrence X Visual or Olfactory Evidence D Soil Contamination D Groundwater Contamination
D Water Supply Well Contamination D Surface Water Contamination
X Other (specify) Eye witness account of historical activity.
SOURCE OF CONTAMINATION
Source of Release Cause of Release Type of Release Product Type Released
(Check one to indicate primary (Check one to indicate primary (Check one) (Check one to indicate primary petroleum product
source) cause) type released)
D AST (tank) D AST Piping/ Dispenser D AST Delivery Problem D OTR Vehicle Tank D OTR Bulk Transport Tank D RR Bulk Transport Tank D Transformer
D Unknown
X Other AST pipe/OTR/Spill
Definitions presented on reverse
X Spill (Accidental) X Spill (Intentional) D Corrosion
D Physical or Mechanical Damage D Equipment Failure D AST Overfill D AST Installation Problem D Unknown D Other Definitions presented on reverse
D Petroleum X Both Petroleum
& Non-Petroleum

Location
(Check one)
X Facility D Residence D Highway/Road D Railway D Other
D Gasoline/ Diesel/ D Diesel/Veg. Oil
Kerosene Blend D E11 – E20 D Vegetable Oil 100% D E21 – E84 D Heating Oil D E85 – E99 D Waste Oil D Ethanol 100% D Mineral Oil-no PCBs D Mineral Oil-PCBs X Other Petroleum
Products Sealer
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
Guidance presented on reverse
UST Form 62 (04/10) 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
List of Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
1.
2.
3.
PARTY RESPONSIBLE FOR RELEASE
(if the source of the release is not an AST system or if it is an AST system and there is a responsible party other than the AST system owner/ operator)
Name of Person/Company WSH Construction, Inc. f/k/a Carolina Site
Concepts, Inc.
Address 11611 Reames Rd.
City Charlotte State NC Zip Code 28269 Telephone Number 704-532-3836
AST SYSTEM OWNER (if the source of the release is an AST system)
AST Owner/Company Piedmont Parking Solutions, LLC dba Carolina Site Address 11611 Reames Rd.
City Charlotte State NC Zip Code 28269 Telephone Number
AST SYSTEM OPERATOR (if the source of the release is an AST system)
UST Operator/Company Piedmont Parking Solutions, LLC dba Carolina Site Address
City State Zip Code Telephone Number
LANDOWNER AT LOCATION OF INCIDENT
Landowner Silas W. Davis Address 13334 Bally Bunnion Way
City Davidson State NC Zip Code 28036 Telephone Number Unknown
Draw Sketch of Area or Provide Map (showing incident site, location of release, two major road intersections, potential
receptors)
Attach sketch or map to form. See attached Figures 1 & 2
Give Directions to Incident Site Attach directions to form if necessary. See attached Figures 1 & 2
Person Reporting Incident Andy Kosse, PG Company Civil & Environmental Consultants, Inc. Telephone Number 980-260-2038
Title Project Manager Address 3701 Arco Corp. Dr., Ste. 400, Charlotte, NC 28273 Date 01.16.23
UST Form 62 (04/10) Page 2 of 2
Definitions of Sources
AST (Tank): means the tank is used to store product
AST Piping: means the piping and connectors running from the tank to the dispenser or other end-use equipment
AST Dispenser: includes the dispenser and the equipment used to connect the dispenser to the piping
AST Delivery Problem: identifies releases that occurred during product delivery to the tank.
OTR Vehicle Tank: means the tank is used to store product to fuel an over the road vehicle
OTR Bulk Transport Tank: means a tank that is used to transport product in bulk over the road (by truck)
RR :bulk Transport Tank: means a tank that is used to transport product in bulk by train
Transformer: means electrical transformer
Other: serves as the option to use when the release source is known but does not fit into one of the preceding categories
Unknown: identifies releases for which the source has not been determined
Definitions of Causes
Spill (Accidental): use this cause when a spill occurs accidentally(e.g., when the delivery hose is disconnected from a fill pipe)
Spill (Intentional): use this cause when a spill occurs intentionally (e.g., intentional dumping or breakage)
Corrosion: use when a metal tank, piping, or other component has a release due to corrosion
Physical or Mechanical Damage: use for all types of physical or mechanical damage, except corrosion
Equipment failure: use when a release occurs due to equipment failure other than corrosion or physical or mechanical damage
AST 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)
AST Installation Problem: use when the problem is determined to have occurred specifically because the AST system was not installed properly
Other: use this option when the cause is known but does not fit into one of the preceding categories
Unknown: use when the cause has not been determined
Guidance: Ownership and Operator Type
Ownership select the category which describes owner of the AST system, bulk transport tank, or other release source
Operator Type select the category which describes the operation in which owner uses the AST system, bulk transport tank, or other release source
CAROLINA
CONCRETE
(LAST)
CURRENTLY
VACANT
LEASE PARCEL
PIN 02504209
CAROLINA SITE
PIN 02504223
MORGAN CORP
(LUST, UST)
HILLS
MACHINERY
COMPANY
DONALD E. PENNINGER
GARAGE
REFERENCE
DATE:DWG SCALE:
DRAWN BY:CHECKED BY:APPROVED BY:
PROJECT NO:
FIGURE NO.:
SITE LOCATION MAP
321-5751"=200'NOV 2022
DLY AJK AJK 1
CAROLINA SITE
LIMITED PHASE II ASSESSMENT
11611 REAMES ROAD
CHARLOTTE, NORTH CAROLINA 28269
www.cecinc.com
3701 Arco Corporate Drive · Suite 400 · Charlotte, NC 28273
Ph: 980.237.0373 · Fax: [phone]
NORTH
REFERENCE
www.cecinc.com
3701 Arco Corporate Drive · Suite 400 · Charlotte, NC 28273
Ph: 980.237.0373 · Fax: [phone]
NORTH
DATE:DWG SCALE:
DRAWN BY:CHECKED BY:APPROVED BY:
PROJECT NO:
FIGURE NO.:
PIT LOCATION MAP
321-5751"=30'NOV 2022
DLY AJK AJK 2
CAROLINA SITE
LIMITED PHASE II ASSESSMENT
11611 REAMES ROAD
CHARLOTTE, NORTH CAROLINA 28269
Table 1Summary of Laboratory ResultsCarolina Site ‐ PIN 02504209Charlotte, NC 28269Soil‐to‐WaterMSCCResidential MSCC Industrial/CommercialMSCC Action Level Sealant*S‐1S‐2S‐3S‐4S‐5S‐6S‐7S‐8Sample Date9/14/2022 9/14/2022 9/14/2022 9/14/2022 9/14/2022 9/14/2022 9/14/20229/14/2022 9/14/2022Soil TypeFill Native Fill Native Fill Native Fill NativeSample Depth‐Ft.NA 0.80           2.5 1.0 3.5 1.5 3.5 1.5 7.5SemiVolatile Organic Compounds‐PAHs (SVOC‐PAHs 8270)Anthracene640 4,600 70,000‐‐2,8000.69j ND 70 ND 18 ND ND NDBenzo(a)anthracene0.17 7 32‐‐2,2005ND120ND76ND ND 0.18jBenzo(a)pyrene0.058 0.66 3.2‐‐1,800 13ND140ND100ND ND 0.29jBenzo(b)fluoranthene0.6 6.6 32‐‐1,90015 ND160ND120ND ND 0.32jBenzo(k)fluoranthene5.8 66 327‐‐9904.6 ND 67 ND 41 ND ND 0.12jCarbazoleNL NL NL‐‐1,700 ND ND 20 ND 5.2 ND ND NDChrysene18 663 3,270‐‐2,100 6.4 ND 120 ND 73 ND ND 0.17jDibenz(a,h)anthracene0.19 0.66 3.27‐‐ND 2.4 ND23ND18ND ND NDFluorene55 625 9,340‐‐1,200 ND ND 34 ND 5.8 ND ND NDIndeno(1,2,3‐cd)pyrene1.9 6.63 32.7‐‐1,2008.8 ND78ND61ND ND 0.16jNaphthalene0.2 5.5 27‐‐1,200ND ND 19 ND 1.6j ND ND NDPyrene210 469 7,000‐‐6,700 9 ND 210 ND 110 ND ND 0.20jVolatile Organic Compounds (VOCs) 8260D (µg/kg)Naphthalene 0.2 5.5 27‐‐730NA NA NA NA NA NA NA NA‐‐NA NA NA NA NA NANotes:* Virgin Tarconite emulsion sealant, other contaminants present, only those also found in soil samples indicated1)  MSCC = NCDEQ UST Section ‐ Comprehensive Tables for Corrective Action Guidelines, March 7, 2022 Version‐ Table 1 Maximum Soil Contaminant Concentration Levels (MSCC) 2)  Soil action level ‐ Guidelines for Site Checks, Tank Closure, and Initial Response and Abatement, May 17, 2021 Version3)  ND = Not Detected4)  NA = Not Analyzed5)  Bold = constituent concentration exceeds Industrial/Commercial MSCC 6)  j = Estimated Concentration, concentration above method detection limit but less than laboratory reporting limit7)  Shaded = exceeds soil‐to‐groundwater MSCCParameterNCDEQ Comparison Criteria (mg/kg) Soil Sample ‐ Concentration of Constituents