WI-8121_43144_CA_UST-3_20230126

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 Raleiqh.
SEE MAP ON THE BACK OF THIS FORM FOR THE CENTML AND REGIONAL OFFICE ADDRESSES.
STATE USE ONLY
Date Received_
I,D,
TNSTRUCTTONS (READ THrS FlRST)
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 Licensed
Geologist (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 andlor 28 forms, should be submitted to the
appropriate Division of Waste Management (DWM) Regional Office within thirty (30) days following closure activities. The UST-2 form should also be
submitted 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 out.
Note: 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 Guidelines for Site Checks, Tank Closure
and lnitial Response. The guidelines can be obtained at lrlfps //dgq-Jlc qQ!/.al . Note: To close tanks in place you must
obtain prior approval from the DWM Regional office located in the region where the facility is located.
You must make sure that USTs removed from your property are disposed of properly. When choosing a closure contractor, ask where the tank(s) will be
taken for disposal. Usually, USTs are cleaned and cut up for scrap metal. This is dangerous work and must be performed by a qualified company. Tanks
disposed of illegally in fields or other dumpsites can leak petroleum products and sludge into the environment. lf your tanks are disposed of improperly, you
could be held responsible for the cleanup of any environmental damage that occurs.
I. OWNERSHIP OF TANKS lt. LocATtoN
Owner Jrlame (Corporation, lndividual, Public Agency, or Other Entity)
Circle K Stores, lnc.
Facility Name or Company
Circle K Store#2720484
Street Address
1100 Situs Court, Suite 100
Facility lD # (lf known)
00-0-0000022582City CountyRaleigh Wake
Street Address
5800 Castle Havne Road
Zip Code
27606
State
NC
City County Zip CodeWilmington New Hanover 28429
Phone Number I Email919-774-6700 | [e-mail]
Phone Number
91977467
II1. CONTACT PERSONNEL
Name:
Alan Cubberlev
Company Name:
Circle K Stores
Job Title:
Sr Manaqer Risk Control
Phone Number:
91977467oO
IV. TANK REMOVAL, CLOSURE N PLACE, CHANGE.IN SERVICE
1.
?.
3.
Contact local fire marshal.
Plan entire closure event.
Conduct Site Soil Assessment.
lf removing tanks or closing in place, refer to
API Publication 2015 Cleaning Petroleum
Storage lanks and 1604 Removal and
Disposal of Used Underground Petroleum
Storaoe Tanks.
Provide a sket'ch 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
8.
a P.E. or L.G., with all closure site assessment
reports bearing the signature and seal of the
P.E. or L.G. lf a release has not occurred, the
supervision, signature or seal of a P.E. or L.G.
is not required.
Keep closure records for three (3) years.
6.
7.
V. WORK TO BE PERFORMED BY
Contractor Name:
Shawn Tucker
Contractor Company Name:
Terra Nova
Address:
901 East Springfield Road
State:
NC
Zip Code:
27263
Phone No:
336-999-3861
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
Prooosed Activitv
Closure Chanqe-ln-Service
Removal Abandonment in Place'New Contents Stored
1 I 0000 Gasoline, Gas Mix
2 I 0000 Gasoline, Gas Mix
3 1 0000 Gasoline, Gas Mix
^ Prior written approval to abandon a tank in place must be received from a DWM Regional Office.
VII. OWNER OR OWNER'S AUTHORIZED REPRESENTATIVE
Has a release from a UST system occurred at this location? X y". E No E 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
Siqnature Date Signed
01t2612023
SCHEDULED REMOVAL DATE
Week February 20,2023
Notify your DWM Regional Office
48 hours before this date if
scheduled removal date changes
-3 Rev 3/2020
XX
X
L]lt