WS-5839_20966_C_NRP_20171024_UNRECRD

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NOTICE OF RESIDUAL PETROLEUM

Servco #01711, 850 N. Liberty Street, Winston-Salem, Forsyth County, North Carolina (site name) 20966________, ______2680/1499-1500__________________________________
(Incident Number) (Deed Book, Pages of Property Deed to be Restricted) The property that is the subject of this Notice (hereinafter referred to as the “Site”) contains residual
petroleum and is an Underground Storage Tank (UST) incident under North Carolina’s Statutes and Regulations, which consist of N.C.G.S. 143-215.94 and 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 Environment Quality (or its successor in function), as authorized by N.C.G.S. Section 143B-279.9 and 143B-279.11. The North Carolina Department of Environment Quality 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 Forsyth County Register of Deeds’ office
Source Property William L. Spencer, The Winston-Salem Drive In, LLC_ of P.O. Box 450 Welcome, NC 27374 is the
owner in fee simple of all or a portion of the Site, which is located in the County of Forsyth, State of North Carolina, and is known and legally described as:

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Additional Affected Property Not Subject to Restrictions

Additionally, residual petroleum is also located on the following property. The following property
is not subject to land use restrictions pursuant to N.C.G.S. Section 143B-279.9(b). The following property is known and legally described as:

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.
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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___.
NC DEPARTMENT OF ENVIRONMENTAL QUALITY

By: _________________________________________________
Winston-Salem Regional Office Supervisor, UST Section
Signatory’s name typed or printed: Carin Lee Kromm

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: ______________________________________________
Date: ________________________ ________________________________ (Official Seal) (signature of Notary Public)
________________________________ (printed or typed name of Notary Public) Notary Public My commission expires:_____________