WA-1195_13993_G_NORR_20191205_NRP INSTR

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INSTRUCTIONS FOR PREPARING A 'NOTICE OF RESIDUAL PETROLEUM'
REFERENCING LAND USE RESTRICTIONS FOR FILING AT A SITE IMPACTED BY A PETROLEM RELEASE FROM AN UNDERGROUND STORAGE TANK The following list of instructions will assist in the preparation and filing of a Notice of Residual Petroleum for a petroleum release from an underground storage tank.
1. The notice and any included restrictions must be agreed to by the owner of the real property, included in
a remedial action plan for the site that has been approved by the Secretary, and implemented as part of the remedial action program for the site. The Secretary may approve restrictions included in the remedial action plan in accordance with standards that the Secretary determines to be applicable to the site.
2. The Notice shall be prepared in accordance with the format provided in these instructions and shall include reference to the appropriate land use restrictions. (REWORDING OF THE NOTICE IS NOT RECOMMENDED AND WILL SUBSTANTIALLY DELAY APPROVAL.)
3. The Notice shall include a description that would be sufficient as a description in an instrument of conveyance of the (i) real property on which the source of contamination is located and (ii) any real property on which contamination is located at the time the remedial action plan is approved and that was owned or controlled
by any owner or operator of the underground storage tank or other responsible party at the time the discharge or release of petroleum is discovered or reported or at any time thereafter.
4. The Notice shall also identify the location (legal description) of any residual petroleum on other real
property on which contamination is known to exist at the time the Notice is prepared and that is a result of the release.
5. The Notice shall reference any restrictions on the current or future use of the real property that are imposed by the Secretary to protect public health, the environment, or users of the property
6. If the contamination is located on more than one parcel or tract of land, the Department may require that the owner, operator, or other person responsible for the discharge or release prepare a composite map or plat that shows the impacted parcels or tracts. Regardless of whether a plat is required, a separate text Declaration of Perpetual Land Use Restriction shall be prepared as part of the Notice to be filed with the applicable county
Register of Deeds. If the contamination is located on one parcel or tract of land, the owner, operator, or other person responsible for the discharge or release may prepare a map or plat that shows the parcel but is not required to do so.
7. Any required survey plat shall be entitled “NOTICE OF RESIDUAL PETROLEUM”, shall be prepared and certified by a professional land surveyor, and shall meet all requirements in G.S. 47-30 for maps and plats, all requirements in G.S. 143B-279.11(c) for the recordation of residual petroleum, and all requirements specified by
the county Register of Deeds. (ALL CONTENTS OF THE PLAT MUST BE DRAWN IN INDELIBLE INK.) Any required Notice plat shall include one or more descriptions that would be sufficient as a description in an instrument of conveyance and shall identify all areas designated by the Department, including:
a. Property lines, north arrow, scale, bearings and distances as appearing on the deed;
b. With respect to permanently surveyed benchmarks, the location and dimensions of any disposal area or area where contamination is known to exist in:
- groundwater at a concentration exceeding the standard or interim standard established in 15A NCAC 2L. 0202, and/or
- soil at a concentration exceeding the residential maximum soil contaminant concentration established in 15A NCAC 2L .0411;
c. Other areas of potential environmental concern, such as all visible and apparent rights-of-way,
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watercourses, utilities, roadways, and other such improvements or structures whether wholly contained
within, or crossing or forming any boundary for a disposal area or area of contamination;
d. The following language: "The areas of contamination depicted upon the map are approximations derived from the best available information at the time of filing.”;
e. The type, location, and quantity of contamination known to the owner of the site to exist on the site;
f. Any restriction approved by the Department on the current or future use of the site to protect public health, the environment, or users of the property;
g. The printed name(s) and title(s) and properly notarized signature(s) of individual(s) with authority to legally bind the responsible party(ies) (i.e., the responsible party(ies), an individual with power of attorney for the responsible party(ies), officer of a corporation, etc.) (PRINTED TEXT, SIGNATURES, AND
NOTARY SEALS, AS WITH ALL MARKINGS ON THE PLAT, MUST BE MADE IN INDELIBLE INK);
h. The following language, for use by the Department, positioned in the upper left corner of the plat:
"Approved for the purposes of N.C.G.S. 143B-279.9 and 143B-279.11 ,
(signature of Regional Supervisor) , Regional Supervisor
(printed name of Regional Supervisor) Regional Office
(name of Region) Underground Storage Tank Section Division of Waste Management Department of Environmental Quality NORTH CAROLINA
COUNTY

I certify that the following person(s) personally appeared before me this day, each acknowledging to me that he or she signed the foregoing document:
(printed full name of Regional Supervisor). WITNESS my hand and official seal, this the ______ day of _______________, 20____.
(Official Seal)

(signature of Notary Public)
(printed or typed name of Notary Public) Notary Public My commission expires:

i. Surveyor's certification and seal (using a permanent ink stamp).
8. Once complete, the signed and notarized Notice declaration (and plat, if required,) shall be sent to the appropriate UST Section Regional Office for review.
9. After the Department approves, notarizes and returns the Notice declaration (and plat, if required,) the responsible party shall, within thirty (30) days of its return:
a. If applicable, file the approved Notice plat in the County Register of Deeds' office of the county or counties in which the site is located, with the applicable plat book(s) and page number(s) from recordation immediately added to the Notice declaration as a reference;
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b. File the Notice declaration in the County Register of Deeds' office of the county or counties in which the
site is located; and
c. Send to the appropriate UST Section Regional Office, a certified copy of the Notice declaration (and plat, if required,) affixed with the seal of the Register of Deeds and reflecting the book(s) and page number(s)
where recorded, along with a copy of the page(s) in the grantor index where the Notice(s) are referenced.
NOTICE OF RESIDUAL PETROLEUM
, County, North Carolina
(Site name) The property that is the subject of this Notice (hereinafter referred to as the “Site”) contains residual petroleum and is a petroleum release incident from an Underground Storage Tank (UST) under North Carolina’s Statutes and Regulations, which consist of Article 21A of Chapter 143 of the General Statutes (N.C.G.S.) and the regulations adopted thereunder. This Notice is part of a remedial action for the Site that has been approved by the Secretary (or his/her delegate) of the North
Carolina Department of Environmental Quality (or its successor in function), as authorized by N.C.G.S. Sections 143B-279.9 and 143B-279.11 for the purpose of protecting public health and the environment. The North Carolina Department of Environmental Quality (or its successor in function) shall hereinafter be referred to as “DEQ”. NOTICE

Petroleum product was released and/or discharged at the Site. Petroleum constituents remain on the site, but are not a danger to public health and the environment, provided that the restrictions described herein, and any other measures required by DEQ pursuant to N.C.G.S. Sections 143B-279.9 and 143B-279.11, are strictly complied with. This "Notice of Residual Petroleum" is composed of a description of the property, the location of the residual petroleum, and the land use restrictions on the Site. The Notice has been approved and notarized by DEQ pursuant to N.C.G.S. Sections 143B-279.9 and 143B-279.11 and has/shall be recorded at the Greene County Register of Deeds’ office in Book , Page .
SOURCE PROPERTY
of is the owner in fee
(Owner’s name) (city & state of owner) simple of all or a portion of the Site, which is located in the County of Greene, State of North Carolina, and is known and legally described as:

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(Insert Real Property Description Here for Source Property)
For protection of public health and the environment, the following land use restrictions required by N.C.G.S. Section 143B-279.9(b) shall apply to all of the above-described real property. These restrictions shall continue in effect as long as residual petroleum remains on the site in excess of unrestricted use
standards and cannot be amended or cancelled unless and until the Greene County Register of Deeds receives and records the written concurrence of the Secretary (or his/her delegate) of DEQ (or its successor in function).
DECLARATION OF PERPETUAL LAND USE RESTRICTIONS
Soil: The Site shall be used for industrial/commercial use only. Industrial/commercial use means a use where exposure to soil contamination is limited in time and does not involve exposure to children or other sensitive populations such as the elderly or sick. The real property shall not be
developed or utilized for residential purposes including but not limited to: primary or secondary residences (permanent or temporary), schools, daycare centers, nursing homes, playgrounds, parks, recreation areas and/or picnic areas.
Groundwater: Groundwater from the site is prohibited from use as a water supply. Water supply wells of any kind shall not be installed or operated on the site ENFORCEMENT The above land use restriction(s) shall be enforced by any owner, operator, or other party responsible for the Site. The above land use restriction(s) may also be enforced by DEQ through any of the
remedies provided by law or by means of a civil action, and may also be enforced by any unit of local government having jurisdiction over any part of the Site. Any attempt to cancel this Notice without the approval of DEQ (or its successor in function) shall be subject to enforcement by DEQ to the full extent of the law. Failure by any party required or authorized to enforce any of the above restriction(s) shall in no event be deemed a waiver of the right to do so thereafter as to the same violation or as to one occurring prior or subsequent thereto.
IN WITNESS WHEREOF, has caused this Notice to be executed pursuant to N.C.G.S. Sections 143B-279.9 and 143B-279.11, this day of , 20

(name of responsible party if agent is signing) By:
(signature of responsible party, attorney or other agent if there is one)
(Title of agent for responsible party if there is one) Signatory’s name typed or printed:
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(Note to be deleted on final document - Preparer of document must assure that the correct acknowledgement is used below and complies with changes effective October 1, 2006, and that others are deleted. DO NOT DELETE the DEQ Approval Certification section at the end of this document.)
[Choice One: Instrument signed by one person]
NORTH CAROLINA
COUNTY
(Name of county in which acknowledgment was taken)
I certify that the following person personally appeared before me this day, acknowledging to me
that he or she signed the foregoing document: .
WITNESS my hand and official seal, this the day of , 20
(Official Seal)

(signature of Notary Public)

(printed or typed name of Notary Public) Notary Public My commission expires:

[Choice Two: Acknowledge by attorney in fact] NORTH CAROLINA COUNTY (Name of county in which acknowledgment was taken) I, , a Notary Public for said County and State, do hereby certify that
___ _______________ , attorney in fact for , personally appeared
before me this day, and being by me duly sworn, says that he executed the foregoing and annexed
instrument for and in behalf of the said , and that his authority to execute
and acknowledge said instrument is contained in an instrument duly executed, acknowledged, and
recorded in the office of in the County of ,
State of , on the day of , 20__ and
that this instrument was executed under and by virtue of the authority given by said instrument granting
him power of attorney.
I do further certify that the said ________ acknowledged the due execution of
the foregoing and annexed instrument for the purposes therein expressed for and in behalf of the said
_____________ .
WITNESS my hand and official seal, this the day of , 20
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(Official Seal)

(signature of Notary Public)
(printed or typed name of Notary Public) Notary Public
My commission expires:
[Choice Three: Conveying security interest in personal property of a corporation]
NORTH CAROLINA COUNTY (Name of county in which acknowledgment was taken)
I, ___ ______ _ , a Notary Public for said County and State, do hereby certify that
___ _ personally came before me this day and acknowledged that he is ___ _____ _ __________ of ___ __ and acknowledged, on behalf of ___________ , the grantor, the due execution of the foregoing instrument. WITNESS my hand and official seal, this the day of , 20

(Official Seal)

(signature of Notary Public) (printed or typed name of Notary Public) Notary Public
My commission expires:
DEPARTMENT OF ENVIRONMENTAL QUALITY APPROVAL

Approved for the purposes of N.C.G.S. 143B-279.11

(signature of Regional Supervisor) , Regional Supervisor
(printed name of Regional Supervisor)
Washington Regional Office UST Section
Division of Waste Management Department of Environmental Quality
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NORTH CAROLINA COUNTY
(Name of county in which acknowledgment was taken) I certify that the following person(s) personally appeared before me this day, each acknowledging to me that he or she signed the foregoing document:
(printed full name of Regional Supervisor). WITNESS my hand and official seal, this the day of , 20

(Official Seal)

(signature of Notary Public) (printed or typed name of Notary Public) Notary Public
My commission expires: