RA-29352_48506_CA_UST-3_20220323

UST-3 Notice of lntent: UST Permanent Closure or Change-in-service
Return completed form to:
The DWM Regional Office located in the area where the facility is located Also send a copy to the Central Office in RaleiqhSEE MAP ON THE BACK OF THIS FORM FOR THE CENTRAL AND REGIONAL OFFICE'ADDRESSES
STATE USE ONLY
tD #
Date Received
TNSTRUCTTONS (READ THtS FTRST)
Complete and return a UST-3 form at least thirty (30) days prior to closure or change-in-service activities lf a professional Engineer (p E ) or a LicensedGeologist (L G.) provides supervision for closure or change-in-service site assessment activities and signs and seals all closure reports then at least a five(5) working days' notice is acceptable
Completed UST closure or change-in-service site assessment reports, along with a copy of the UST-2A andtor 28 forms, should be submitted to theappropriate Division of Waste Management (DWM) Regional Office within thirty (30) days following closure activities The UST-2 form should also besubmitted to the Central Office in Raleigh so that the status of the tanks may be changed to permanently closed and your tank fee account can be closed outNote: Tank fees may be due for unregistered tanks.
UST closure and change-in-service site assessments must be completed in accordance with the latest version of the Guidetines for Site Checks, Tank Ctosureand lnitial Response. The guidelines can be obtained at Note: To close tanks in place you mustobtain prior approval from the DWM Regional office located in the region where the facility is located
You must make sure that UST_s removed from your property are disposed of properly. When choosing a closure contractor, ask where the tank(s) will betaken for disposal. Usually, USTs are cleaned and cut up for scrap metal. This is dangerous work and-must be performed by a qualified company. Tanksdisposed of illegally in fields or other dumpsites can leak petroleum products and sludge into the environment lf your tanks aie diiposed of imiroferly, youcould be held responsible for the cleanup of any environmental damage that occurs.
I. OWNERSHIP OF TANKS il. LOCATTON
Owner Name (Corporation, lndividual, Public Agency, or Other Entity)
Circle K Stores, lnc
Facility Name or Company
Circle K Slore #2720104Street Address
1100 Situs Court, Suite 100
Facility lD # (lf known)
00-0-000001 51 30city countyRaleigh Wake Street Address
4835 Hope Valley Road
State
NC
Zip Code
27606 City County Zip CodeDurham Durham 27707Phone Number I Emait919-774-6700 | [e-mail]
Phone Number
91977467ooIII. CONTACT PERSONNEL
Company Name:
Circle K Stores
Name:
Alan Cubberlev Job Title:
Sr Manaqer Risk Control
Phone Number
91977467(c).-)IV. TANK REMOVAL, CLOSURE IN PLACE, CHANGE-IN SERVICE
a P E or L G , with all closure site assessment
reports bearing the signature and seal of the
P E orLG lf a release has notoccurred, the
supervision, signature or seal of a P.E or L.G
is not required
Keep closure records for three (3) years
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7
51
2
Contact local fire marshal
Plan entire closure event.
Conduct Site Soil Assessment
lf removing tanks or closing in place, refer toAPI Publication 2015 Cleaning Petroleum
Sforage Tanks and 1604 Removat and
Disposa/ of Used Underground Petroleum
Storage Tanks
Provide a sketch locating piping, tanks and
soil sampling locations
Submit a closure report in the format of UST-
12 (including the form UST-2) within thirty
(30) days following the site investigation
lf a release from the tanks has occurred, the
site assessment portion of the tank closure
must be conducted under the supervision of
V. WORKTO BE PERFORMED BY
Contractor Name:
Jeremy DeVore
Contractor Company Name:
Zebra Environmental
Address:
901 East Springfield Road
State:
NC
Zip Code:
27263
Phone No:
336-442-1129
Primary Consultant Name:
Maureen A Jackson, PG
Primary Consultant Company Name:
ATC Associates of NC
Consultant Phone No:
91 9-561 -3893
VI. TANKS SCHEDULED FOR CLOSURE OR CHANGE-IN-SERVICE
Tank lD No Size in Gallons Last Contents
Proposed Activity
Closure Change-l n-Service
Removal Abandonment in Place New Contents Stored
1 1 0000 Gasoline, Gas Mix
2 1 0000 Gasoline, Gas Mix
J 8000 Gasoline, Gas Mix x
4 8000 Dielsel, Dielsel Mix x trtrtr
Regional OfficeVII. OWNER OR OWNER'S AUTHORIZED REPRESENTATIVE
Has a release from a UST system occurred at this location? [ ves E ruo ! Unknown
I understand that I can be held responsible for environmental damage resulting from the improper disposal of my USTs
Print name and official title: Maureen A Jackson PG Sr PM ATC on behalf of Circle K Stores
/Erg(alure^ I;Y h 'r^r-'^hbb Date Signed
03123t2022
SCHEDULED REMOVAL DATE
Week of May 2,2022
Notify your DWM Regional Office
48 hours before this date if
scheduled removal date changes
UST-3 Rev 3/2020
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