WA-1034_12709_I_O_20190327

0BUST Closure Inspection Checklist
Inspection Date: Closure Type: (Removal / Abandonment) Facility ID#
I.Inspector Safety (Circle appropriate responses to the following questions)
1.Fire Marshall present / notified of UST closure
2.Site Safety Plan is present: Yes / No (Inspector should sign plan. If plan is not present inspector should leave site.)
3.Time of inspector arrival: ____________ 4. Time of Inspector departure: _5. Inspector's Name:__________
II. Ownership of Tanks III. Location of Tanks
_________________________________________________________
Owner's Name (Corporation, Individual, Public Agency, or other entity)
_________________________________________________________
Street Address
_________________________________________________________
City State Zip Code
_________________________________________________________
Area Code Phone Number
_________________________________________________________
Contact Person for UST Location Phone #
_________________________________________________________
Date became owner of the UST systems
______________________________________________________________
Facility Name
______________________________________________________________
Street Address
______________________________________________________________
County City (nearest) Zip Code
______________________________________________________________
Number of UST systems on site (including non-regulated)
______________________________________________________________
Operator Name Facility Phone #
______________________________________________________________
Current use of the site
IV.Contractor InformationPrimary Consultant: __________________________________________________ Phone #: _______________________
Address: _________________________________________________ City: _______________ State:_____ ZIP: ________
General Contractor: ____________________________________________________ Phone #: _____________________
Address: _________________________________________________ City: ________________ State:____ ZIP: ________
Laboratory: __________________________________________________________ Phone #: _______________________
Address: _________________________________________________ City: ________________ State: ___ ZIP: _________
V. UST Information
Tank#1 Tank#2 Tank#3 Tank#4 Tank#5 Tank#6
1. Is the UST regulated? (Y/N)
2. Date last operated
3. Substance Stored (G-Gasoline, D-Diesel, etc.)
4. Material of construction (Tanks)
5. Material of construction (Piping)
6. Dimensions of Tank (Diameter X Length (ft.))
IV. UST Closure Information (Respond to the following questions with Yes, No, or ? Did Not Observe)
1. Product removed from UST?
2. Vapors purged from UST?
3. UST filled with solid inert material (ifabandoned)?
4. Depth of UST below ground surface (ft.)?
5. Soil staining observed ABOVE tank?
6. Holes in UST observed?
7. Soil staining observed BELOW tank?
8. Free product observed in excavation?
9. Groundwater in excavation?
10. Bedrock at base of excavation?
3/27/2019 00-2-0000017866
Yes
10:00 am 4:00 pm C. Stone / J. Edwards
Etheridge Oil and Gas, Inc.
Post Office Box 65
Englehard NC 27824
252 925-4301
Thomas J. Etheridge, III 252 925-4301
ETHCO Service Station
34970 US Hwy 264, Englehard, NC
Hyde Englehard 27824
12,000 Gallon Gas Compartmentalized Gasoline UST (A1&A1B)
Thomas Etheridge [phone]
Geological Resources, Inc. William Regenthal 704-845-4010
Greenwood Applied Services, LLC, Wood Beasley 252-398-6022
Post Office Box 238 Colerain NC 27924
113 W. Firetower Rd, Suite G.Winterville NC 28590
06/28/1994
Y Y
G G
DWS DWS
SWF SWF
Y Y
Y Y
NA NA
3 ft 3ft
Y Y
N N
GW GW
N N
Y Y
N N
Dare County Fire Marshall present,
UST Closure Inspection Checklist (Cont.)
Inspection Date: Page 2 of 2 Facility ID#
1BVII. Sampling Procedures 2BVIII. Excavation and Stockpile
_________________________________________________________
3. Number and location of samples appropriate for:
Tanks: Y N Piping: Y N Dispensers: Y N
4. Planned Lab analytical methods appropriate? Y N
5.Any samples collected by DENR personnel? Y N
1. Final Excavation Dimensions (ft .X ft .X ft.) _________________________
2. Did excavation continue after tank removal? Yes No
3. Any indication excavation soils contaminated? Yes No
4. Stockpile properly constructed: Yes No
5. Stockpile samples collected: Yes No
6. Destination of Tank(s):
______________________________________________________________
7. Destination of excavated soils:
______________________________________________________________
3BComments:
Site Map: (Show North Arrow, Roads (name), Buildings/Other landmarks, Utilities (overhead and subsurface), WSWs or other receptors, Adjacent properties, USTs (numbered), Piping, Dispensers, Sample Locations, Areas of Staining, Stockpile)
I, ______________________ certify that all of the information given to (Inspector) on (Date) is true and accurate to the best of my belief. SIGNATURE:_____________________________
Closure Checklist 11/2005
3/27/2019 00-2-0000017866
Contaminated material was observed coming from spill buckets. Unknown whether this material was contained to the spill
buckets only. IMs not present during initial uncovering of USTs by contractors. Contaminated soil was apparently observed
by consultant in samples collected at the spill buckets. Groundwater depth in excavation pit was approximately 4-5 feet.
Depth to water in canals was approximately 1-2 feet bgs. Historical depth to groundwater in site monitoring wells ranges from less than a foot to 4-5 feet bls. Soil samples were being collected approx. 1-2 feet deep, at or above shwt. Estimated 15-25 tons of contaminated soil to be hauled off. No soil was approved for removal by TF . IMs observed tank beingremoved from excavation pit without incident. Tank appears to be in very good condition, no pitting or holes observed.
Approximate location of excavation limits highlighted.
No soil to be stockpiled, cont. soil to be hauled off for disposal
unknown1.Sample Collection method (auger, backhoe, shovel, etc.)
backhoe/auger
2.Sample preservation method (ice, refrigerator, acid, etc.)
Yes
Carrie Stone
to be determined
ETHCO Service Station, UST Inc. 12709 Englehard, NC