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HomeMy WebLinkAboutMO-29269_48436_CA_UST-61_20211105_24 Hour Release and UST Leak Reporting FormUST-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? (YIN) Y Facility ID Number NA Incident# Risk (H,I,L,U) Confirmed GW Contamination? (YIN)N Date Leak Discovered 11/2/2021 Received On Received By Confirmed Soil Contamination ?(YIN) Y Comm/Non-Commercial? Non -Comm Reported by (circle one): Phone, Fax or Report Samples Taken?(YIN) Y Reg/Non-regulated? Non -Reg. Region Free Product? (YIN) N If Yes, State Greatest Thickness INCIDENT DESCRIPTION Incident Name: 15901 Cramur Road Address: 15901 Cramur Road County: Mecklenburg Regional Office (circle one): AshevilleVooresvilb Fayetteville, City/Town: Huntersville Zip Code:28078 Raleigh, Washington, Wilmington, Winsto - aem Latitude (decimal degrees): 35.428333 N Longitude (decimal degrees) : 80.913889 W 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 ❑GIS Address matching Mother ❑unknown Describe location: Soil assessment activities were conducted at the site in October, 2021 in the area of two out -of -service heating oil USTs located at the site. Concentrations of TPH DRO & GRO that exceeded the RALs were reported in samples collected. The USTs were removed from the site on 111212021. Concentrations of TPH DRO & GRO that exceeded RALs were reported in the samples collected from excavated soils and from the walls and base of one of the UST basins. Ground Water was not encountered. 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 X❑ Property Transfer ❑Water Supply Well Contamination ❑Other (specify) SOURCE OF CONTAMINATION Source of Release Cause of Release Type of Release Product Type Released (Check primary source) (Check primary cause) (Check one) (Check primary product type released) ❑X Tank ❑ spill M Petroleum ❑ Gasoline/ Diesel/ ❑ Diesel/Veg. Oil ❑ Piping ❑ Overfill ❑ Non -Petroleum Kerosene Blend ❑X El Dispenser Corrosion Both Heating Oil ❑ Vegetable Oil 100% ❑X ❑ ❑ Other Petroleum ❑ E10 — E20 ❑ Submersible Turbine Pump ❑ Physical/Mechanical Location Products El Delivery Problem Damage (Check one) ❑ E21 — E84 ❑ Metals ❑ Install Problem ❑ E85 — E99 ❑ Spill Bucket ❑ Other Inorganics ❑ Other X❑Facility ❑Ethanol 100% ❑ Other ❑ Other Organics El unknown ❑Residence ❑ E01 — E09 ❑ Unknown [:]Other Definitions presented on reverse Definitions presented on reverse Ownership 1. Municipal 2. Military 3. Unknown 4. 40D5. Federal 6. County 7. State Operation Type 1. Public Service 2. Agricultural 3. Residential 4. Education/Relig. 5. Industrial 6. ommercia 7. Mining UST Form 61 (02/19) Page 1 of 2 IMPACT ON DRINKING WATER SUPPLIES Water Supply Wells Affected? 1. Yes 2. No 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 Shirley Keistler Point of Contact Address Shirley Keistler 15905 Cramur Dr. City Huntersville State NC Zip Code Telephone Number 28078 Unknown UST SYSTEM OPERATOR UST Operator/Company Shirley Keistler Address 15905 Cramur Dr. City Huntersville State NC Zip Code 28078 Telephone Number Unknown LANDOWNER AT LOCATION OF UST INCIDENT Landowner Shirley Keistler Address 15905 Cramur Dr. City Huntersville State NC Zip Code 28078 Telephone Number Unknown Draw Sketch of Area (showing two major road intersections) or Attach Map See attached Maps Person Reporting Incident Scott Ball CompanyGeological Resources, Inc. Telephone Number (704) 845-4010 Title Project Manager Address 3502 Hayes Rd., Monroe, NC 28110 Date 11/5/2021 UST Form 61 (02119) 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 (mown 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 MECKLENBURG COUNTY, North Carolina POLARIS 3G PARCEL OWNERSHIP AND GIS SUMMARY Date Printed Identity Parcel ID GIS ID 00102370 100102370 Property Characteristics Legal desc L1 M69-10 Land Area 1.29 AC Fire District HUNTERSVILLE Special District FIRE SERVICE D Account Type INDIVIDUAL Municipality HUNTERSVILLE Zoning Contact appropriate Planning Department or see Map. Water Quality Buffer Parcel Inside Water Quality Buffer I No FEMA and Community Floodplain FEMA Panel# 3710462100J FEMA Panel Date 03/02/2009 FEMA Flood Zone OUT:VIEW FEMA FLOODPLAIN TO VERIFY Community Flood Zone OUT:VIEW COMMUNITY FLOODPLAIN TO VERIFY 11 /05/2021 Ownership Owner Name Mailing Address SHIRLEY T/A KEISTLER 15905 CRAMUR DR HUNTERSVILLE NC 28078 Deed Reference(s) and Sale Price Deed Fsale Date I Sale Price 17228-907 05/21 /2004 1$0.00 Site Location ETJ Area Huntersville Charlotte Historic District No Charlotte 6/30/2011 Annexation Area No Census Tract # 62.04 Post Construction District Jurisdiction Huntersville District Huntersville Stream Watershed Districts Stream Watershed Name LAKE NORMAN Regulated Drinking Watershed Districts Watershed Name LAKE NORMAN Watershed Class CA Built -Upon Area Restriction Situs Addresses Tied to Parcel Limit on amount of Built -Upon Area Yes CRAMUR DR HUNTERSVILLE This map or report is prepared for the inventory of real property within Mecklenburg County and is compiled from recorded deeds, plats, tax maps, surveys, planimetric maps, and other public records and data. Users of this map or report are hereby notified that the aforementioned public primary information sources should be consulted for verification. Mecklenburg County and its mapping contractors assume no legal responsibility for the information contained herein. Page 1/1 r =m 't' 4 • r r Oft •' Plantation LightFIR ' ,A,� . w..' � 5601 +Cramur i6e 41 sm .* `� ^ af: �ir� a;. 1. i- f!.�i T•' �c off'`VW- Lie Earth 0+ 3 i21 0 E 0 U O m I M n in H U W O D_ i 0 c: c E c 0 i LAKE NORMAN / THIS DRAWING IS FOR EXHIBIT PURPOSES ONLY. IT IS TO SHOW RELATIVE LOCATIONS OF SOIL SAMPLE LOCATIONS WITHIN AN / APPROXIMATE SOIL EXCAVATION AREA AS SHOWN HEREON. IT IS NOT MEANT FOR CONVEYANCES, SALES OR RECORDING. NO BOUNDARY WORK, RESEARCH OR UTILITY LOCATIONS WERE DONE WITHIN THE SCOPE OF THIS EXHIBIT. ALL LOCATIONS AND \ PARCEL LINES ARE APPROXIMATE AND 15915 CRAMUR DRIVE / \ NOT TO SCALE. 15905 CRAMUR DRIVE EXHIBIT PURPOSES ONLY NOT TO SCALE / BUILDING SB-1 UST DRO: 5,340 mgA 15901 CRAMUR GRO: 121 mg/kg DRIVE /C3 qz / I I SB-2X SB-2XX / I SB-2 / \ TREE \ tp DRO:< 12.5 mg/ \ UST GRO: < 6.27 mg/kg WATER WELL \ V Ove \ ENCLOSURE \ 15101 NC HIGHWAY 73 / a(Lo o a �J Fm Dy LL —C _ c 0 N� D oo 0.N LL�N mw 0 Ww �_Z moa W 9 C v 0) NZ� z �3 WZ� w E �o F. VWz N 1.410-01 r, Z� O 0 CO w W Q�z aka O�L71x� �-3ZU) PLO 0 MZ N Lo 1� DRAWN BY: GHL CHECKED BY: GH PROJECT NUMBER: 7736.0921ED SCALE: NOT TO SCALE DATE: 10/14/2021 DRAWING: 15901 Cramur Dr -Figure 1 Copyright 2021 CES Group Engineers, LLP Beverly, Trudy From: Beverly, Trudy Sent: Friday, November 5, 2021 9:53 AM To: Scott Ball Cc: Tomie Benton Subject: RE: [External] 15901 Cramur Drive, Huntersville, NC - HHO UST removal Received. Thank you Scott. Have a great weekend, Trudy Trudy Beverly, L.G. Hydrogeologist, Division of Waste Management North Carolina Department of Environmental Quality Q, Dr" 'el UST Section, Mooresville Regional Office 704.235.2182 (Office) Trudy. B everlykncdenn 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: ht_pt s://deg.nc.gov/about/divisions/waste-management/ust Branch's Above Ground Storage Tanks Website Address: https:Hdeg.nc.gov/about/divisions/waste-management/ust/ast-program INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES: httos://dea.nc. gov/about/divisions/waste-management/waste-management-rules-data/waste-management-ais-mans File Review Procedures: hops://deq.ne. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche): bit.ps://deq.nc.gov/about/divisions/waste-management/laserfiche Document Submittal & UST File Names for Laserfiche Policies: htti)s:Hfiles.ne.izov/ncdea[Waste%2OMana2ement/DWM/UST/WhatsNew/Final-Electronic-Document-Submittal-Policv.l)df https:Hfiles.nc.gov/ncdeq/Waste%2OManagement/D WM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx From: Scott Ball[mailto:wsb@geologicalresourcesinc.com] Sent: Friday, November 5, 2021 9:51 AM To: Beverly, Trudy <trudy.beverly@ncdenr.gov> Cc: Tomie Benton<tmb@geologicalresourcesinc.com> Subject: RE: [External] 15901 Cramur Drive, Huntersville, NC - HHO UST removal CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to Report Spam. Trudy Please see attached. Thanks Scott Ball Project Manager Geological Resources, Inc. 3502 Hayes Road Monroe, NC 28110 Main (704) 845-4010 Fax (704) 845-4012 carriekennedy@geologicalresourcesinc.com www.geologicalresourcesinc.com NCPCM Vendor of the Year Recipient From: Beverly, Trudy <trudy.beverly@ncdenr.gov> Sent: Friday, November 5, 2021 8:33 AM To: Scott Ball <wsb@geologicalresourcesinc.com> Cc: Tomie Benton<tmb@geologicalresourcesinc.com> Subject: RE: [External] 15901 Cramur Drive, Huntersville, NC - HHO UST removal Good Morning Scott, The UST-61 form has not been submitted for this release. Please email me a pdf of the completed form. UST-61 24-Hour Release and UST Leak Reporting Form https://deg.nc.gov/about/divisions/waste-management/ust/forms Thank you, Trudy Trudy Beverly, L.G. D�. E Hydrogeologist, Division of Waste Management North Carolina Department of Environmental Quality "'"" UST Section, Mooresville Regional Office mental 4u'Yly� 704.235.2182 (Office) Trudy. B everlykncdenr. 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: ht_pt s://deg.nc.gov/about/divisions/waste-management/ust Branch's Above Ground Storage Tanks Website Address: https://deq.nc.gov/about/divisions/waste-management/ust/ast-pro2Tam INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES: httns://dea.nc. eov/about/divisions/waste-management/waste-management-rules-data/waste-manaeement-ais-mans File Review Procedures: https://deq.ne. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche): httDs: //dea.nc. eov/about/divisions/waste-mana2ement/laserfiche Document Submittal & UST File Names for Laserfiche Policies: htti)s:Hfiles.ne.izov/nedeafWaste%2OMana2ement/DWM/UST[WhatsNew/Final-Electronic-Document-Submittal-Policv.l)df https:Hfiles.nc.gov/ncdeq/Waste°/`20Management/DWM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx From: Scott Ball [mailto:wsb@geologicalresourcesinc.com] Sent: Friday, November 5, 2021 7:34 AM To: Beverly, Trudy <trudy.beverly@ncdenr.gov> Cc: Tomie Benton<tmb@geologicalresourcesinc.com> Subject: [External] 15901 Cramur Drive, Huntersville, NC - HHO UST removal CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to Report Spam. Hi Trudy We have removed the two heating oil USTs at this site and confirmed soil contamination. The release was discovered in October 2021 during Phase II ESA activities conducted by CES. My question is, was a UST-61 form ever submitted to the NCDEQ for the release? If not, should I submit one now for your/NCDEQ's records? I will be preparing the IAAR in the next few days. Thanks Scott Ball Project Manager Geological Resources, Inc. 3502 Hayes Road Monroe, NC 28110 Main (704) 845-4010 Fax (704) 845-4012 carriekennedy@geologicalresourcesinc.com www.geologicalresourcesinc.com NCPCM Vendor of the Year Recipient