WS-29697_48881_C_UST-2_20230125

UST-2A Site Investigation Report for Permanent Closure or Change-in-
Service of
REGISTERED UST

Return completed form to:
NC DEQ / DWM / UST SECTION
1646 MAIL SERVICE CENTER
RALEIGH, NC 27699-1646
ATTN: REGISTRATION & PERMITTING phone [phone] fax [phone] http://www.wastenotnc.org/

STATE USE ONLY: Facility ID # Date Received
INSTRUCTIONS (READ THIS FIRST)
1. UST permanent closure or change in service must be completed in accordance with the latest version of the Guidelines for Site Checks, Tank
Closure and Initial Response and Abatement. The guidelines can be obtained at http://deq.nc.gov/about/divisions/waste-management/waste-management-permit-guidance/underground-storage-tanks-section.
2. Permanent closure: Complete all sections of this form.
3. Change-in-service: Where a UST system will be converted from storing a regulated substance to a non-regulated substance, complete sections I, II, III, IV, and VI
4. For more than 5 registered UST systems, attach additional forms as needed
5. Tank Fee Refund: An annual tank fee may be refunded for a tank for which a tank fee was not required. An owner or operator must submit
a written request and include: (1) contact information, (2) federal identification # or SSN, and (3) a copy of UST-2 form. The annual tank
fee will be prorated based on the date of permanent closure.
6. UNREGISTERED USTs use Form UST-2B
I. OWNERSHIP OF TANKS II. LOCATION OF TANKS
Owner Name (Corporation, Individual, Public Agency, or Other Entity) Facility Name or Company Street Address Facility ID # (If known) City County Street Address State
Zip Code
City County Zip Code Phone Number Phone Number
III. CONTACT PERSONNEL Contact for Facility: Job Title: Phone #:
Closure Contractor Name: Closure Contractor Company: Address: Phone #
Primary Consultant Name: Primary Consultant Company: Address: Phone #
IV. UST INFORMATION FOR REGISTERED UST SYSTEMS UNREGISTERED USTs use Form UST-2B V. EXCAVATION CONDITION
Tank ID No. Size in Gallons Last Contents Last Use Date
Permanent Close Date Method of Permanent Closure: Indicate REMOVED or enter fill material, such as foam/ concrete/ sand
Change-in-Service Date Water in excavation Free product
Notable odor or visible soil contamination Yes No Yes No Yes No

VI. CERTIFICATION
I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and all attached documents and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true accurate and complete.
Print name and official title of owner or owner’s authorized representative
Signature Date Signed
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION 1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE [phone] FAX [phone] http://www.wastenotnc.org/ 1/2016

Norma R. Hiatt
145 Windward Drive
Mount Airy Surry
NC 27030
336-710-9579
Roy G. Hiatt
00-0-0000008327
139 Tumbling Rock Drive
Mount Airy 27030Surry
336-710-9579
Chris Hiatt 336-972-7981
Justin Radford Geological Resources, Inc 3502 Hayes Road, Monroe, NC 704-845-4010
Eric Eubanks Geological Resources, Inc 3502 Hayes Road, Monroe, NC 704-845-4010
A1 12,000 Diesel Unknown01/23/23 REMOVED 01/23/23
Eric M. Eubanks, P.G. - Staff Scientist
01/25/23