HomeMy WebLinkAboutMO-29676_48800_CA_UST-61_20221222_24-Hour Release and UST Leak Reporting Form.UST-61
24-Hour Release and UST Leak Reporting Form.
For Releases This form should be completed and submitted to the UST Section's regional office following a known or suspected release from
an underground storage tank (UST) system. This form is required to be submitted within 24 hours of discovery of a known or
in NC suspected release
(DWM USE ONLY)
Suspected Contamination? (Y/N) Y
Facility ID Number
Incident # Risk (H,I,L,U)
Confirmed GW Contamination? (Y/N) N
Date Leak Discovered 9-30-2022
Received On Received By
Confirmed Soil Contamination ?(Y/N) Y
Comm/Non-Commercial?Non-Comm
Reported by (circle one): Phone, Fax or Report
Samples Taken?(Y/N) Y
Reg/Non-regulated? Non -Regulated
Region
Free Product? (Y/N) N If Yes, State Greatest
Thickness
INCIDENT DESCRIPTION
Incident Name: 4521 Hershey Street Residence
Address: 4521 Hershey Street
County: Mecklenburg
Regional Office (circle one): Ashevill ooresville ayetteville,
City/Town: Charlotte
zip Code: 28213
Raleigh, Washington, Wilmington, Winston- a em
Latitude (decimal degrees): 35.2607 Longitude (decimal degrees) : _80. 7891
Obtained by:
❑ GPS
Briefly describe suspected or confirmed release: (including but not limited to: nature of release, date of release, amount
of release, amount of free product present and recovery efforts, initial responses conducted, impacts to receptors
Topographic map
Petroleum contamination was discovered at a residential heating oil UST during due diligence activities
❑ GIS Address matching
❑ Other
❑ Unknown
Describe location:
for a potential real estate transaction. Laboratory analysis of a soil sample collected at the tank
detected a TPH-DRO concentration of 14,400 mg/kg and TPH-GRO concentration of 664 mg/kg. The site
location is shown on the attached USGS topographic map excerpt (Figure 1). Soil cleanup activities are
anticipated during UST removal activities.
HOW RELEASE WAS DISCOVERED (Release code)
(Check one)
❑ Release Detection Equipment or Methods ❑ Visual/Odor ❑ Groundwater Contamination
❑ During UST Closure/Removal ❑ Water in Tank ❑ Surface Water Contamination
50 Property Transfer ❑ Water Supply Well Contamination ❑ Other (specify)
SOURCE OF CONTAMINATION
Source of Release Cause of Release Type of Release Product Type Released
(Check one to indicate primary (Check one to indicate primary (Check one) (Check one to indicate primary product type
source) cause) released)
M Tank ❑ Spill Petroleum ❑ Gasoline/ Diesel/ ❑ Diesel/Veg. Oil
Kerosene Blend
❑ Piping ❑Overfill ❑Non -Petroleum M
❑
Heating Oil Vegetable Oil 100%
❑ Dispenser N Corrosion ❑ Both ❑ Other Petroleum ❑ E10 — E20
❑ Submersible Turbine Pump ❑ Physical or Mechanical Products
❑ E21 E84
—
Damage Location ❑ Metals
❑ Delivery Problem ❑ E85 E99
❑
cone Other Inorganics —
❑ Install Problem (Check )
❑ Other ❑ Other ❑ Other Organics ❑ Ethanol 100%
❑Facility
❑ Unknown
❑ ❑ Residence ❑ E01 — E09
Unknown
Definitions presented on reverse I Definitions presented on reverse I ❑ Other
Ownership
1. Municipal 2. Military 3. Unknown 4 Private 5. Federal 6. County 7. State
Operation Type
1. Public Service 2. Agricultural < Residential . Education/Relig. 5. Industrial 6. Commercial 7. Mining
UST Form 61 (02/08) Page 1 of 2
IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected? 1. Yes 2. No 3 Unknown
Number of Water Supply Wells Affected
Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
1.
2.
3.
UST SYSTEM OWNER
UST Owner/Company
Erasmo Valensuela
Point of Contact
Address
Harry Youchak, Elite Carolinas (owner's rep.)
2060 Ayrsley Town Blvd., #A
City
State
Zip Code
Telephone Number
Charlotte
NC
28273
(704) 351-7344
I
UST SYSTEM OPERATOR I
UST Operator/Company
Address
Erasmo Valensuela
1123 Rankin Oaks Street
City
State
Zip Code
Telephone Number
Charlotte
NC
28213
LANDOWNER AT LOCATION OF UST INCIDENT I
Landowner
Address
Erasmo Valensuela
1123 Rankin Oaks Street
City
State
Zip Code
Telephone Number
Charlotte
NC
28213
Draw Sketch of Area (showing two major road intersections) or Attach Map
See the attached Site Plan (Figure 2) showing the location of the former heating oil UST.
Stephen C. Brown 704 593-1640
Person Reporting Incident
Company The El Group, Inc.
Telephone Number
Title Senior Project Manager
Address 201 McCullough Drive, Suite 155
Date 11-28-2022
UST Form 61 (02/08) Charlotte, N.C. 28262 Page 2 of 2
Definitions of Sources
Tank: means the tank that stores the product and is part of the underground storage tank system
Piping: means the piping and connectors running from the tank or submersible turbine pump to the dispenser or other end -use equipment (Vent, vapor recovery, or fill
lines are excluded.)
Dispenser: includes the dispenser and the equipment used to connect the dispenser to the piping (e.g., a release from a suction pump or from components located above
the shear valve)
Submersible Turbine Pump (STP) Area includes the submersible turbine pump head (typically located in the tank sump), the line leak detector, and the piping that
connects the submersible turbine pump to the tank
Delivery Problem: identifies releases that occurred during product delivery to the tank. (Typical causes associated with this source are spills and overfills.)
Other: serves as the option to use when the release source is known but does not fit into one of the preceding categories (e.g., for releases from vent lines, vapor
recovery lines, and fill lines)
Unknown: identifies releases for which the source has not been determined
Definitions of Causes
Spill: use this cause when a spill occurs (e.g., when the delivery hose is disconnected from the tank fill pipe or when the nozzle is removed from the dispenser)
Overfill: use when an overfill occurs (e.g., overfills may occur from the fill pipe at the tank or when the nozzle fails to shut off at the dispenser)
Physical or Mechanical Damage: use for all types of physical or mechanical damage, except corrosion (e.g., puncture of tank or piping, loose fittings, broken
components, and components that have changed dimension)
Corrosion: use when a metal tank, piping, or other component has a release due to corrosion (e.g., for steel, corrosion takes the form of rust)
Installation Problem: use when the problem is determined to have occurred specifically because the UST system was not installed properly
Other: use this option when the cause is known but does not fit into one of the preceding categories (e.g., putting regulated substances into monitoring wells)
Unknown: use when the cause has not been determined
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REFERENCE: USGS Topographic Map; Derita, North Carolina Quadrangle; dated 1993. N
FIGURE NUMBER: 1 TOPOGRAPHIC MAP
Single -Family Residence
PROJECT NUMBER: ENCH220022.00 4521 Hershey Street
SCALE: 1"=2,000' Charlotte, North Carolina
former
UST
R
_19
;444
r w
4
� r
Source: Mecklenburg County GIS system via the Internet and EI field notes
FIGURE NUMBER: 2 SITE PLAN
DRAWN BY: SCB
Single -Family Residence _
PROJECT NUMBER: ENCH220022.00 4521 Hershey Street
SCALE: Not To Scale Charlotte, North Carolina
leAnalyiical
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Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
(704)875-9092
September 30, 2022
Stephen C Brown
The El Group
201 McCullough Dr
Suite 150
Charlotte, NC 28262
RE: Project: HERSHEY ST./ENL0220842.01
Pace Project No.: 92626605
Dear Stephen Brown:
Enclosed are the analytical results for sample(s) received by the laboratory on September 20, 2022. The results relate only
to the samples included in this report. Results reported herein conform to the applicable TNI/NELAC Standards and the
laboratory's Quality Manual, where applicable, unless otherwise noted in the body of the report.
The test results provided in this final report were generated by each of the following laboratories within the Pace Network:
• Pace Analytical Services - Charlotte
If you have any questions concerning this report, please feel free to contact me.
Sincerely, Ck,c.
U
Bonnie Vang
bonnie.vang@pacelabs.com
(704)875-9092
Project Manager
Enclosures
cc: Brandon Corolla, The El Group
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Page 1 of 11
lacmnalyfica('
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Pace Analytical Services, LLC
9800 KinceyAve. Suite 100
Huntersville, NC 28078
(704)875-9092
Project: HERSHEY ST./ENL0220842.01
Pace Project No.: 92626605
Pace Analytical Services Charlotte
South Carolina Laboratory ID: 99006
9800 Kincey Ave. Ste 100, Huntersville, NC 28078
North Carolina Drinking Water Certification #: 37706
North Carolina Field Services Certification #: 5342
North Carolina Wastewater Certification #: 12
South Carolina Laboratory ID: 99006
CERTIFICATIONS
South Carolina Certification #: 99006001
South Carolina Drinking Water Cert. #: 99006003
Florida/NELAP Certification #: E87627
Kentucky UST Certification #: 84
Louisiana DoH Drinking Water #: LA029
Virginia/VELAP Certification #: 460221
REPORT OF LABORATORY ANALYSIS
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Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
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(704)875-9092
Project: HERSHEY ST./ENL0220842.01
Pace Project No.: 92626605
Lab ID Sample ID
92626605001 UST-S
SAMPLE SUMMARY
Matrix Date Collected Date Received
Solid 09/19/2210:35 09/20/2213:57
REPORT OF LABORATORY ANALYSIS
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without the written consent of Pace Analytical Services, LLC.
Page 3 of 11
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SAMPLE ANALYTE COUNT
Project: HERSHEY ST./ENL0220842.01
Pace Project No.: 92626605
Analytes
Lab ID Sample ID
Method
Analysts
Reported
Laboratory
92626605001 UST-S
EPA 8015C
AP2
2
PASI-C
EPA 8015C
TEG
2
PASI-C
SW-846
KDF
1
PASI-C
PASI-C = Pace Analytical Services - Charlotte
REPORT OF LABORATORY ANALYSIS
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without the written consent of Pace Analytical Services, LLC. Page 4 of 11
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ANALYTICAL RESULTS
Project: HERSHEY ST./ENL0220842.01
Pace Project No.: 92626605
Sample: UST-S
Lab ID: 92626605001 Collected: 09/19/22 10:35 Received: 09/20/22 13:57 Matrix: Solid
Results reported on a "dry weight"
basis and are adjusted for percent moisture, sample size and any dilutions.
Report
Parameters
Results Units Limit MDL DF Prepared
Analyzed CAS No. Qual
8015 GCS THC-Diesel
Analytical Method: EPA 8015C Preparation Method: EPA 3546
Pace Analytical Services - Charlotte
Diesel Range Organics(C10-
14400 mg/kg 343 243 50 09/23/22 11:36
09/23/22 18:13
C28)
Surrogates
n-Pentacosane (S)
0 % 10-130 50 09/23/22 11:36
09/23/22 18:13 629-99-2 S4
Gasoline Range Organics
Analytical Method: EPA 8015C Preparation Method: EPA 5030E
Pace Analytical Services - Charlotte
Gas Range Organics (C6-C10)
664 mg/kg 11.5 3.2 1 09/21/22 10:47
09/21/22 23:46
Surrogates
4-Bromofluorobenzene (S)
167 % 66-130 1 09/21/22 10:47
09/21/22 23:46 460-00-4 S5
Percent Moisture
Analytical Method: SW-846
Pace Analytical Services - Charlotte
Percent Moisture
26.3 % 0.10 0.10 1
09/20/22 16:58 N2
REPORT OF LABORATORY ANALYSIS
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Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
(704)875-9092
QUALITY CONTROL DATA
Project: HERSHEY ST./ENL0220842.01
Pace Project No.: 92626605
QC Batch: 724720
Analysis Method: EPA 8015C
QC Batch Method: EPA 5030E
Analysis Description: Gasoline Range Organics
Laboratory: Pace Analytical Services - Charlotte
Associated Lab Samples: 92626605001
METHOD BLANK: 3775723
Matrix: Solid
Associated Lab Samples: 92626605001
Blank Reporting
Parameter
Units
Result Limit MDL
Analyzed
Qualifiers
Gas Range Organics (C6-C10)
mg/kg
2.5J 5.9 1.6
09/21/22 14:16
4-Bromofluorobenzene (S)
%
97 66-130
09/21/22 14:16
LABORATORY CONTROL SAMPLE:
3775724
Spike LCS LCS
% Rec
Parameter
Units
Conc. Result % Rec
Limits Qualifiers
Gas Range Organics (C6-C10)
mg/kg
49.5 49.9 101
70-130
4-Bromofluorobenzene (S)
%
99
66-130
MATRIX SPIKE SAMPLE:
3775726
92626343002 Spike MS
MS
% Rec
Parameter
Units
Result Conc. Result
% Rec
Limits Qualifiers
Gas Range Organics (C6-C10)
mg/kg
ND 71.7 84.4
114
65-146
4-Bromofluorobenzene (S)
%
104
66-130
SAMPLE DUPLICATE: 3775725
92624835014 Dup
Max
Parameter
Units
Result Result RPD
RPD
Qualifiers
Gas Range Organics (C6-C10)
mg/kg
ND ND
30
4-Bromofluorobenzene (S)
%
97 97
Results presented on this page are in the units indicated by the "Units" column except where an alternate unit is presented to the right of the result.
REPORT OF LABORATORY ANALYSIS
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Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
(704)875-9092
QUALITY CONTROL DATA
Project: HERSHEY ST./ENL0220842.01
Pace Project No.: 92626605
QC Batch: 725372
Analysis Method: EPA 8015C
QC Batch Method: EPA 3546
Analysis Description: 8015 Solid GCSV
Laboratory: Pace Analytical Services - Charlotte
Associated Lab Samples: 92626605001
METHOD BLANK: 3779105
Matrix: Solid
Associated Lab Samples: 92626605001
Blank Reporting
Parameter
Units
Result Limit MDL
Analyzed
Qualifiers
Diesel Range Organics(C10-C28)
mg/kg
ND 5.0 3.6
09/23/22 17:06
n-Pentacosane (S)
%
89 10-130
09/23/22 17:06
LABORATORY CONTROL SAMPLE:
3779106
Spike LCS LCS
% Rec
Parameter
Units
Conc. Result % Rec
Limits Qualifiers
Diesel Range Organics(C10-C28)
mg/kg
66.7 48.5 73
44-130
n-Pentacosane (S)
%
77
10-130
MATRIX SPIKE SAMPLE:
3779152
92626282001 Spike MS
MS
% Rec
Parameter
Units
Result Conc. Result
% Rec
Limits Qualifiers
Diesel Range Organics(C10-C28)
mg/kg
ND 73 52.4
66
10-130
n-Pentacosane(S)
%
68
10-130
SAMPLE DUPLICATE: 3779153
92626282002 Dup
Max
Parameter
Units
Result Result RPD
RPD
Qualifiers
Diesel Range Organics(C10-C28)
mg/kg
6.6 ND
30
n-Pentacosane (S)
%
93 67
Results presented on this page are in the units indicated by the "Units" column except where an alternate unit is presented to the right of the result.
REPORT OF LABORATORY ANALYSIS
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Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
(704)875-9092
QUALITY CONTROL DATA
Project: HERSHEY ST./ENL0220842.01
Pace Project No.: 92626605
QC Batch: 724555 Analysis Method: SW-846
QC Batch Method: SW-846 Analysis Description: Dry Weight/Percent Moisture
Laboratory: Pace Analytical Services - Charlotte
Associated Lab Samples: 92626605001
SAMPLE DUPLICATE: 3775159
Parameter
Percent Moisture
SAMPLE DUPLICATE: 3775160
Parameter
Percent Moisture
92626592004 Dup
Units Result Result
21.7 22.1
92626525007 Dup
Units Result Result
% 2.3 2.6
Max
RPD RPD Qualifiers
2 25 N2
Max
RPD RPD Qualifiers
10 25 N2
Results presented on this page are in the units indicated by the "Units" column except where an alternate unit is presented to the right of the result.
REPORT OF LABORATORY ANALYSIS
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QUALIFIERS
Project: HERSHEY ST./ENL0220842.01
Pace Project No.: 92626605
DEFINITIONS
DF - Dilution Factor, if reported, represents the factor applied to the reported data due to dilution of the sample aliquot.
ND - Not Detected at or above adjusted reporting limit.
TNTC - Too Numerous To Count
J - Estimated concentration above the adjusted method detection limit and below the adjusted reporting limit.
MDL -Adjusted Method Detection Limit.
PQL - Practical Quantitation Limit.
RL - Reporting Limit - The lowest concentration value that meets project requirements for quantitative data with known precision and
bias for a specific analyte in a specific matrix.
S - Surrogate
1,2-Diphenylhydrazine decomposes to and cannot be separated from Azobenzene using Method 8270. The result for each analyte is
a combined concentration.
Consistent with EPA guidelines, unrounded data are displayed and have been used to calculate % recovery and RPD values.
LCS(D) - Laboratory Control Sample (Duplicate)
MS(D) - Matrix Spike (Duplicate)
DUP - Sample Duplicate
RPD - Relative Percent Difference
NC - Not Calculable.
SG - Silica Gel - Clean -Up
U - Indicates the compound was analyzed for, but not detected.
Acid preservation may not be appropriate for 2 Chloroethylvinyl ether.
A separate vial preserved to a pH of 4-5 is recommended in SW846 Chapter 4 for the analysis of Acrolein and Acrylonitrile by EPA
Method 8260.
N-Nitrosodiphenylamine decomposes and cannot be separated from Diphenylamine using Method 8270. The result reported for
each analyte is a combined concentration.
Reported results are not rounded until the final step prior to reporting. Therefore, calculated parameters that are typically reported as
"Total" may vary slightly from the sum of the reported component parameters.
Pace Analytical is TNI accredited. Contact your Pace PM for the current list of accredited analytes.
TN -The NELAC Institute.
ANALYTE QUALIFIERS
N2 The lab does not hold NELAC/TNI accreditation for this parameter but other accreditations/certifications may apply. A
complete list of accreditations/certifications is available upon request.
S4 Surrogate recovery not evaluated against control limits due to sample dilution.
S5 Surrogate recovery outside control limits due to matrix interferences (not confirmed by re -analysis).
REPORT OF LABORATORY ANALYSIS
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QUALITY CONTROL DATA CROSS REFERENCE TABLE
Project:
Pace Project No.:
HERSHEY ST./ENL0220842.01
92626605
Analytical
Lab ID
Sample ID
QC Batch Method
QC Batch Analytical Method
Batch
92626605001
UST-S
EPA 3546
725372 EPA 8015C
725506
92626605001
UST-S
EPA 5030B
724720 EPA 8015C
724774
92626605001
UST-S
SW-846
724555
REPORT OF LABORATORY ANALYSIS
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Date: 09/26/2022 08:56 AM without the written consent of Pace Analytical Services, LLC. Page 10 of 11
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*
Beverly, Trudy
From: Beverly, Trudy
Sent: Thursday, December 22, 2022 1:18 PM
To: Stephen Brown
Subject: RE: [External] 4521 Hershey St. IAA Report and UST-61
Received.
Trudy
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
_ North Carolina Department of Environmental Quality
�poruxnS o7 Lm7ronmrnng�' UST Section, Mooresville Regional Office
704.235.2182 (Office)
Trudy. B everly(d) ncdenr. gov
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
Office Mailing Address:
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Branch's Underground Storage Tanks Website Address: hops://deq.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: hgps://deg.nc.gov/about/divisions/waste-management/ust/ast-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
https://deq.nc.gov/about/divisions/waste-management/waste-management-rules-data/waste-mana eg ment-gis-maps
File Review Procedures:
https://deq.nc. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
hi�2s://deg.nc.gov/about/divisions/waste-manaaement/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
htti)s:Hfiles.ne.izov/nedea[Waste%2OMana2ement/DWM/UST/W hatsNew/Final-Electronie-Document-Submittal-Policy.odf
https:Hfiles.nc. gov/ncdeg/Waste%20Management/DWM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx
From: Stephen Brown <sbrown@eil.com>
Sent: Thursday, December 22, 2022 1:10 PM
To: Beverly, Trudy <trudy.beverly@ncdenr.gov>
Subject: [External] 4521 Hershey St. IAA Report and UST-61
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
No shallow bedrock or groundwater was encountered in the UST basin over excavation.
Harry Youchak shown on the attached UST-61 is RP's representative.
His email is youbuild@yahoo.com
Merry Christmas!!
Stephen
Stephen C. Brown
Senior Project Manager, Environmental Services
The El Group, Inc.
Environmental, Health and Safety Solutions
201 McCullough Drive, Suite 150
Charlotte, North Carolina 28262
Office: 704 . 593. 1640
Mobile: 704. 264. 4189
www.eil.com