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Home My WebLink AboutWS-29857_48956_CA_CLO_20230324 3502 Hayes Road • Monroe, North Carolina 28110 113 West Firetower Road, Suite G • Winterville, North Carolina 28590 Phone (704) 845-4010 • (888) 870-4133 • Fax (704) 845-4012 March 24, 2023 Mr. James Brown NCDEQ-UST Section Winston-Salem Regional Office 450 W. Hanes Mill Road Suite 300 Winston-Salem, NC 27105 Re: UST Closure Report November 2022 -March 2023 NSC; 102 Hayden Place 102 Hayden Place High Point, Guilford County North Carolina Facility ID Number: 00-0-0000035017 Incident Number: N/A GRI Project Number: 4908 Dear Mr. Brown, Please find enclosed the referenced report for the abovementioned site. If you have any questions, please contact Sam McKay at 704-845-4010. Sincerely, Geological Resources, Inc. Leslie Maxtone-Graham Administrative Assistant Enclosure Cc: Mr. Michael Hall; Petroleum Equipment and Service, Inc., file 3502 Hayes Road • Monroe, North Carolina 28110 113 West Firetower Road, Suite G • Winterville, North Carolina 28590 Phone (704) 845-4010 • (888) 870-4133 • Fax (704) 845-4012 Engineering Certification: C-2727 • Geology Certification: C-127 UST Closure Report November 2021 - March 2023 NSC; 102 Hayden Place 102 Hayden Place High Point, Guilford County North Carolina 27260 Facility ID Number: 00-0-0000035017 Incident Number: N/A GRI Project Number: 4908 Prepared for: Mr. Michael Hall Petroleum Equipment and Service, Inc. P.O. Box 1949 Denver, NC 28037 March 23, 2023 Samuel L. McKay, P.G. License # 2105 Xavier T. Farmer Report Writer _____________________________________________________________________________________ Prepared by: Geological Resources, Inc. UST Closure Report Prepared on: March 23, 2023 NSC; 102 Hayden Place Project Manager: Samuel L. McKay GRI Project No. 4908 i EXECUTIVE SUMMARY NSC; 102 Hayden Place is currently an office building for North State Telephone Company. The site is located at 102 Hayden Place in High Point, Guilford County, North Carolina. The adjoining properties are commercial. Municipal water is available to the site. The site contained one UST basin in an alleyway on the southern side of the building. The UST basin contained one 5,000-gallon heating oil UST. This UST was closed in place at the site on November 4, 2021. No soil was excavated during UST closure activities. Following UST closure activities, four soil borings (SB- 1 through SB-4) were advanced to 12 feet BGS surrounding the UST on March 6, 2023. These samples were submitted for analysis of TPH-GRO and TPH-DRO using the UVF Method. No concentrations of TPH- GRO or TPH-DRO exceeded the Action Levels Based on these results, there is no indication of a release. No further action is required _____________________________________________________________________________________ Prepared by: Geological Resources, Inc. UST Closure Report Prepared on: March 23, 2023 NSC; 102 Hayden Place Project Manager: Samuel L. McKay GRI Project No. 4908 ii SITE INFORMATION 1. Site Identification  NSC; 102 Hayden Place (Facility ID 00-0-0000035017)  Incident Number N/A – Risk Ranking Undetermined  Location of Source Area: 102 Hayden Place High Point, NC 27260 Guilford County 35.957538°N, 80.006636°W (Topographical Map) 2. Information about Contacts Associated with the Leaking UST System UST/AST Owner North State Telephone Co. 111 N. Main St. High Point, NC 27267 Email Unknown Phone No. Unknown UST/AST Operator North State Telephone Co. 111 N. Main St. High Point, NC 27267 Email Unknown Phone No. Unknown Property Owner North State Telephone Co. 111 N. Main St. High Point, NC 27267 Email Unknown Phone No. Unknown Consultant/Contractor Geological Resources, Inc. 3502 Hayes Road Monroe, NC 28110 SMcKay@geologicalresourcesinc .com 704-845-4010 Analytical Laboratory Geological Resources, Inc. 3502 Hayes Road Monroe, NC 28110 SMcKay@geologicalresourcesinc .com 704-845-4010 Closure Contractor PES, Inc. P.O. Box 1949 Denver, NC 28037 mhall@petroleumequipment.com 704-335-8801 3. Information about Release  One 5,000-gallon heating oil UST was closed in place at the site on November 4, 2021. Certification: I, Samuel L. McKay, a Licensed Geologist for Geological Resources, Inc., do certify that the information contained in this report is correct and accurate to the best of my knowledge. Geological Resources, Inc. is licensed to practice geology and engineering in North Carolina. The certification numbers of the corporation are C-127 and C-2727, respectively. _____________________________________________________________________________________ Prepared by: Geological Resources, Inc. UST Closure Report Prepared on: March 23, 2023 NSC; 102 Hayden Place Project Manager: Samuel L. McKay GRI Project No. 4908 iii ACRONYMS ACM: Asbestos Containing Materials AFVR: Aggressive Fluid-Vapor Recovery ARR: Acknowledgement of Report Receipt AS: Air Sparging AST: Aboveground Storage Tank ASTM: American Society for Testing and Materials BGS: Below Ground Surface CAP: Corrective Action Plan CFR: Code of Federal Regulations CSA: Comprehensive Site Assessment DPE: Dual Phase Extraction DRO: Total Petroleum Hydrocarbons Diesel Range Organics DWM: Division of Waste Management DWR: Department of Water Resources EPA: Environmental Protection Agency EPH: Extractible Petroleum Hydrocarbons ESA: Environmental Site Assessment GCL: Gross Contamination Level GRI: Geological Resources, Inc. GRO: Total Petroleum Hydrocarbons Gasoline Range Organics LSA: Limited Site Assessment MAC: Maximum Allowable Concentration as specified in T15A NCAC 2L.0202 MADEP: Massachusetts Department of Environmental Protection MCC: Maximum Contaminant Concentrations MMPE: Mobile Multi-Phase Extraction NAPL: Non-Aqueous Phase Liquid, “Free Product” NCDEQ: North Carolina Department of Environmental Quality NCDOT: North Carolina Department of Transportation NFA: Notice of No Further Action NORR: Notice of Regulatory Requirements NOV: Notice of Violation NPDES: National Pollutant Discharge Elimination System NRP: Notice of Residual Petroleum O&M: Operation and Maintenance PAHs: Polynuclear Aromatic Hydrocarbons PCA: Pre-Construction Assessment RAL: Regulatory Action Level SCLs: Soil Cleanup Level SPCC: Spill Prevention Control and Countermeasures SVE: Soil Vapor Extraction SVOCs: Semi-Volatile Organic Compounds SWPPP: Stormwater Pollution Prevention Plan TCLP: Toxicity Characteristic Leaching Procedure (EPA Method SW-846 1311) TOC: Top of Casing TPH: Total Petroleum Hydrocarbons USGS: United States Geological Survey UST: Underground Storage Tank UVF: Ultraviolet Fluorescence VOCs: Volatile Organic Compounds VPH: Volatile Petroleum Hydrocarbons ____________________________________________________________________________________________ Prepared by: Geological Resources, Inc. UST Closure Report Prepared on: March 23, 2023 NSC; 102 Hayden Place Project Manager: Samuel L. McKay GRI Project No. 4908 1 TABLE OF CONTENTS EXECUTIVE SUMMARY ....................................................................................................................... i SITE INFORMATION ............................................................................................................................ ii ACRONYMS ....................................................................................................................................... iii A. SITE HISTORY AND CHARACTERIZATION ...................................................................................2 B. SITE CHECK ..............................................................................................................................3 C. UST CLOSURE ..........................................................................................................................3 D. FREE PRODUCT INVESTIGATION AND RECOVERY REPORT .........................................................4 E. GROUND WATER INVESTIGATION ............................................................................................4 F. INITIAL RESPONSE AND ABATEMENT ACTION ...........................................................................4 G. EXCAVATION OF CONTAMINATED SOIL ....................................................................................5 H. SOIL AND GROUNDWATER SAMPLE RESULTS ...........................................................................5 I. SUMMARY AND CONCLUSIONS ................................................................................................5 J. LIMITATIONS ...........................................................................................................................6 FIGURES Figure 1: Site Location Map Figure 2: Site Map Figure 3: Soil Sample Location Map Figure 4: Soil Quality Map TABLES Table 1: UST Owner/Operator Information Table 2: UST System Information Table 3: Summary of Soil Sample Analytical Results – UVF results APPENDICES Appendix A: Notice of Intent form (UST-3) Appendix B: Site Investigation Report for Permanent Closure or Change-in-Service of UST (UST-2A) Appendix C: Health and Safety Plan Appendix D: Fluid Disposal Manifest Appendix E: UVF Screening Results ____________________________________________________________________________________________ Prepared by: Geological Resources, Inc. UST Closure Report Prepared on: March 23, 2023 NSC; 102 Hayden Place Project Manager: Samuel L. McKay GRI Project No. 4908 2 A. SITE HISTORY AND CHARACTERIZATION 1. UST Owner and Operator Information: In accordance with the Initial Abatement Action Report guidelines, the UST owner and operator information has been summarized in Table 1. 2. UST System Information: In accordance with the Initial Abatement Action Report guidelines, the UST system information has been summarized in Table 2. A copy of the Registered Tank Report is shown below: 3. Non-UST Information: No ASTs are located at the site. 4. Comprehensive Description of the Release: There is no release associated with this site. The UST was closed in place on November 4, 2021. A Notice of Intent: UST Permanent Closure or change in service (UST-3) Form was submitted to the Winston-Salem Regional office of NCDEQ on October 6, 2020 (Appendix A). 5. Description of the Site Characteristics: The NSC; 102 Hayden Place site is an office building for North State Telephone Company located at 102 Hayden Place in High Point, Guilford County, North Carolina. A topographic map showing the general site location and the surrounding area is included as Figure 1. The site is bordered to the northeast by N. Main Street and to the southeast by Hayden Place. A site map is included as Figure 2. 6. Summary of Initial Abatement Actions, Assessment Activities, and Corrective Actions: Prior to closure, the appropriate officials were notified by GRI (i.e. NCDEQ). A copy of the UST-3 Notice of Intent form is included as Appendix A. One 5,000-gallon heating oil UST and associated piping were closed in place at the site on November 4, 2021. GRI arrived onsite on March 6, 2023, in order to collect closure soil samples, as a well cannot be installed at the site. Ground water was not encountered in the soil borings around or in UST basin. ____________________________________________________________________________________________ Prepared by: Geological Resources, Inc. UST Closure Report Prepared on: March 23, 2023 NSC; 102 Hayden Place Project Manager: Samuel L. McKay GRI Project No. 4908 3 B. SITE CHECK A site check was not part of the initial abatement activities. C. UST CLOSURE 1. Preparation for Closure: A Notice of Intent: UST Permanent Closure or Change-in-Service (UST-3 Form) Form was submitted to the NCDEQ Winston-Salem Regional office on October 6, 2020, and is included as Appendix A. A copy of the Site Investigation Report for Permanent Closure or Change-in-Service of UST Form (UST-2A Form) is included as Appendix B. A copy of the site-specific health and safety plan is included as Appendix C. 2. Closure Procedure: On November 4, 2021, one 5,000-gallon heating oil UST as well as associated product piping were closed in place at the site. The UST was located in an alleyway in between the North State Telephone Company building and the south adjoining building. The dimensions of the UST are not known. The UST was constructed of steel. A disposal manifest for the UST contents that were removed prior to the concrete in-filling of the tank in November 2021 is included as Appendix D. Photos of the 5,000-gallon UST before and after filling with concrete are shown below: 3. Residual Material: Approximately 2,300-gallons of diesel fuel was removed from the UST prior to closure. A copy of the disposal manifest for the fluids recovered during the pump out event is provided as Appendix D. ____________________________________________________________________________________________ Prepared by: Geological Resources, Inc. UST Closure Report Prepared on: March 23, 2023 NSC; 102 Hayden Place Project Manager: Samuel L. McKay GRI Project No. 4908 4 4. Release Information: No release is associated with this UST system closure. 5. Soil Excavation Activities: No soil was removed during this tank closure. 6. Site Investigation: Four soil samples (SB-1 through SB-4) were collected after closure and were analyzed by GRI for TPH-GRO and TPH-DRO using the UVF method. Based on the UVF results, there is not a release onsite. All concentrations of GRO and DRO in the samples are below the action levels. No other samples were taken during the closure. All soil samples were collected using a hand auger. Soil sample locations are shown on Figure 3. A copy of GRI’s UVF screening results are included as Appendix E. D. FREE PRODUCT INVESTIGATION AND RECOVERY REPORT Free product was not encountered during the November 2021 UST closure or March 2023 soil sampling activities. E. GROUND WATER INVESTIGATION Ground water was not encountered during the November 2021 UST closure or March 2023 soil sampling activities. F. INITIAL RESPONSE AND ABATEMENT ACTION 1. Initial Response Actions: One 5,000-gallon fuel oil UST and associated product piping were closed in place at the site on November 4, 2021. No soils were excavated or removed from the site.  Source Control Actions: One 5,000-gallon heating oil UST was closed in place on November 4, 2021.  Contaminant Migration Control Measures: There is no release associated with this UST; therefore, no contaminant migration control measures were necessary.  Measures Taken to Mitigate Fire/Safety Hazards: Prior to closure, the appropriate officials were notified (NCDEQ). Free product was not encountered during closure activities.  Measures Taken to Identify and Mitigate Pollution Hazards: There is no release associated with this UST; therefore, no migration control measures were necessary. 2. Initial Abatement Actions:  Contaminated Soil Storage/Treatment and/or Disposal: No soils were excavated or removed from the site during this scope of work. ____________________________________________________________________________________________ Prepared by: Geological Resources, Inc. UST Closure Report Prepared on: March 23, 2023 NSC; 102 Hayden Place Project Manager: Samuel L. McKay GRI Project No. 4908 5 G. EXCAVATION OF CONTAMINATED SOIL 1. Extent of Soil Contamination: Soil sample results indicate that there is no contamination related to the UST system. No soils were excavated or removed from the site. 3. Sampling Description: All soil samples were collected directly using a hand auger by GRI personnel. Samples were collected with clean, disposable nitrile gloves, immediately placed in laboratory-supplied glassware and placed on ice. H. SOIL AND GROUNDWATER SAMPLE RESULTS  Soil: GRI returned to the site on March 6, 2023, in order to perform UST closure sampling. Four soil borings (SB-1 through SB-4) were advanced to 11 feet BGS in order to collect samples. The concentrations of GRO and DRO were below the action levels in all samples. A Soil Quality Map has been included as Figure 4. Copies of the laboratory reports are included as Appendix G. A summary of the soil sampling data from the March 2023 UST closure activities is show below: Sample ID Sample Depth (ft-BGS) Gasoline-Range TPH Diesel-Range TPH RAL (mg/kg) 50 100 SB-1 11 14.80 23 SB-2 11 <10 7.2 SB-3 11 <10 3.2 SB-4 11 <20 4  Ground Water: Ground water was not encountered during the November 2021 UST closure or the March 2023 sampling activities. I. SUMMARY AND CONCLUSIONS  One 5,000-gallon heating oil UST was closed in place with concrete fill at the site on November 4, 2021.  No free product was noted in the UST basin during closure activities.  GRI returned to the site on March 6, 2023, to conduct closure sampling. The samples were analyzed by GRI for concentrations of TPH-GRO and TPH-DRO.  Ground water was not encountered during the November 2021 UST closure or March 2023 soil sampling activities. ____________________________________________________________________________________________ Prepared by: Geological Resources, Inc. UST Closure Report Prepared on: March 23, 2023 NSC; 102 Hayden Place Project Manager: Samuel L. McKay GRI Project No. 4908 6  The concentrations of GRO and DRO in the samples were below the action levels in all samples.  Based on these results, a release has not occurred at the site. No further assessment is required for this closure. J. LIMITATIONS This report has been prepared for the exclusive use of PES, Inc. and North State Telephone Company for specific application to the referenced site in Guilford County, North Carolina. The assessment was conducted based on the scope of work and level of effort desired by the NCDEQ and with resources adequate only for that scope of work. Our findings have been developed in accordance with generally accepted standards of environmental practices in the State of North Carolina, available information, and our professional judgment. No other warranty is expressed or implied. The data that is presented in this report is indicative of conditions that existed at the precise locations sampled and at the time the samples were collected. In addition, the data obtained from samples would be interpreted as being meaningful with respect to parameters indicated in the laboratory report. No additional information can logically be inferred from this data. FIGURES SITE LOCATIONFigure 1 Site LocationNSC; 102 Hayden Place102 Hayden PlaceHigh Point, North CarolinaGuilford CountyIncident No. N/AGRI Project No. 4908500 M2000 FTDate: 10/16/2021Location: 35.957538° N -80.006636° W Dad TABLES UST ID Number 1 Facility ID Number Owner or Operator? OwnerNorth State Telephone 11/30/1990 - 11/4/2021 Address Telephone Number 102 Hayden Place, High Point, NC Unknown Name of Owner or Operator Dates of Ownership / Operation TABLE 1 UST OWNER/OPERATOR INFORMATION 102 HAYDEN PLACE 00-0-0000035017 Page 1 of 1 Date: 03/13/23 Was Release Associated with UST System? (Yes / No) 1 Heating Oil Heating Oil 5,000 11/30/1990 Single Wall Steel Unk.Single Wall Copper Abandoned No TABLE 2 UST SYSTEM INFORMATION 102 HAYDEN PLACE Facility ID #: 0-035017 UST ID No. Current or Most Recent Contents Previous Contents Capacity (gallons) Date Installed Construction Details Tank Dimensions Description of Associated Product Piping and Pumps Status of UST Page 1 of 1 Date: 03/13/23 Facility ID #: 0-035017 Sample ID Date Collected (mm/dd/yy) Sample Location Sample Depth (ft-BGS) 50 100 SB-1 03/06/23 11 14.80 23 SB-2 03/06/23 11 <10 7.2 SB-3 03/06/23 11 <10 3.2 SB-4 03/06/23 11 <20 4 • RAL: Regulatory Action Level. • < : Less than the UFV method detection limit . • Concentrations in bold face type indicate the RALs were less than the reported concentrations Notes: • Results reported in mg/kg; samples analyzed onsite by UVF. • ft-BGS: feet below ground surface. TABLE 3 SUMMARY OF SOIL SAMPLE ANALYTICAL RESULTS - FIELD DATA 102 HAYDEN PLACE Analytical Method UVF Contaminant of Concern Gasoline-Range TPHDiesel-Range TPHRAL (mg/kg) Soil Borings Page 1 of 1 APPENDICES APPENDIX A Notice of Intent form (UST-3) UST-3 Notice of Intent: 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 Raleigh. SEE MAP ON THE BACK OF THIS FORM FOR THE CENTRAL AND REGIONAL OFFICE ADDRESSES. STATE USE ONLY I.D. #_____________________ Date Received______________ INSTRUCTIONS (READ THIS FIRST) Complete and return a UST-3 form at least thirty (30) days prior to closure or change-in-service activities. If 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 is acceptable. Completed UST closure or change-in-service site assessment reports, along with a copy of the UST-2A and/or 2B 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 Initial Response. The guidelines can be obtained at https://deq.nc.gov/about/divisions/waste-management/ust. 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. If your tanks are disposed of improperly, you could be held responsible for the cleanup of any environmental damage that occurs. I. OWNERSHIP OF TANKS II. LOCATION 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 Email Phone Number III. CONTACT PERSONNEL Name: Company Name: Job Title: Phone Number: IV. TANK REMOVAL, CLOSURE IN PLACE, CHANGE-IN SERVICE 1. Contact local fire marshal. 2. Plan entire closure event. 3. Conduct Site Soil Assessment. 4. If removing tanks or closing in place, refer to API Publication 2015 Cleaning Petroleum Storage Tanks and 1604 Removal and Disposal of Used Underground Petroleum Storage Tanks. 5. Provide a sketch locating piping, tanks and soil sampling locations. 6. Submit a closure report in the format of UST- 12 (including the form UST-2) within thirty (30) days following the site investigation. 7. If a release from the tanks has occurred, the site assessment portion of the tank closure must be conducted under the supervision of a P.E. or L.G., with all closure site assessment reports bearing the signature and seal of the P.E. or L.G. If a release has not occurred, the supervision, signature or seal of a P.E. or L.G. is not required. 8. Keep closure records for three (3) years. V. WORK TO BE PERFORMED BY Contractor Name: Contractor Company Name: Address: State: Zip Code: Phone No: Primary Consultant Name: Primary Consultant Company Name: Consultant Phone No: VI. TANKS SCHEDULED FOR CLOSURE OR CHANGE-IN-SERVICE Tank ID No. Size in Gallons Last Contents Proposed Activity Closure Change-In-Service Removal Abandonment in Place * New Contents Stored *Prior written approval to abandon a tank in place must be received from a DWM Regional Office. Has a release from a UST system occurred at this location? Yes No 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: Signature Date Signed SCHEDULED REMOVAL DATE Notify your DWM Regional Office 48 hours before this date if scheduled removal date changes UST-3 Rev 3/2020 NC Guilford NC APPENDIX B Notice of Intent form (UST-3) 1 5,000 Fuel Oil 11/04/21 11/04/21 Filled with Concrete 10/19/2020 X X X Samuel L. McKay, III, P.G. 3/17/2023 North State Telephone Company North State Telephone Company 111 North Main Street High Point Guilford NC 27260 00-0-0000035017 102 Hayden Place High Point Guilford 27260 Jesse McKenzie Senior Facilities Manager 336-821-8669 Petroleum Equipment ServicesMichael Hall Sam McKay Geological Resources, Inc.704-845-4010 703-335-8801 APPENDIX C Health and Safety Plan 1 GEOLOGICAL RESOURCES, INC. Site Specific Health and Safety Plan 1.0 General Information: a. Project name: NSC; 102 Hayden Place b. Location: 102 Hayden Place, High Point, NC c. GRI Job #: 4908 2.0 Project Organization: a. Site Supervisor/H&S Officer: b. Project Manager: Samuel L. McKay, GRI c. Subcontractor(s): NA 3.0 Safety Plan Preparation: a. Prepared by & date: Sam McKay, 10/13/2021 b. Reviewed/approved by & date: 4.0 Site History and Description: a. Type of site (i.e., spill, leaking UST system, etc.): Leaking UST system b. Site/project description: Commercial property-Telecom facility Current activities include UST abandonment in place, soil sampling & well install. 5.0 Potential Hazards: Physical Hazards: (check) X Slips X Overhead X Explosion Sun burn X Electricity X Trips utilities X Noise X Cold Weather X Pressurized line/vessels X Falls X Underground X Pinch points Hot Weather X Fire utilities X Burns X Crush Chemical Hazards: (check) Gasoline Used Oil X Heating Oil Diesel Solvents Kerosene Antifreeze New Oil Acid (sample preservative) Equipment/Vehicular/Other: (i.e., Geoprobe, drill rig, back hoe, track hoe, traffic, skid steer etc.) Drill rig, equipment Biological Hazards: (i.e., toxic insects, spiders, poisonous plants, poisonous snakes, aggressive dogs) Black widow spiders, snakes 2 6.0 Site Organization and Safety Control: (Evaluate the need for site control to protect persons from exposure to hazardous conditions; i.e. work permits, cones, barricade tape, exclusion zones, etc.) a. Work area(s) identified: __Entire site_________________________________________ b. Work area marked ___X__ Yes ___ No c. Work area barricaded ____ Yes __X___ No d. Support area established: ___GRI truck_______________________________________ e. Entry and escape routes identified: _South – E Naomi St ______________________ f. Rally point identified: __X__ Yes ____ No Location:__ _____ g. Emergency shut-off for water identified ____ Yes _X___ No h. Emergency fuel shut-off identified ____ Yes __X___ No i. Site map attached: __X_ Yes _____ No **Emergency Response Procedures** Action (i.e. shut off all power equipment) Assemble at rally point Call 911 for medical or utilities emergency Do NOT enter confined spaces Discuss what to do if …..cut product line, water line, cable/electric line 7.0 Job Activities in Work Plan: UST Removal X Soil Sampling Manual FP Recovery Soil Excavation System O&M Other (specify) X Powered Drilling __ MMPE/AFVR _____________ X Hand Augering X__ Water sampling _____________ 8.0 Required Education and/or Training: X OSHA 40 hr X Annual 8 hr Refresher OSHA Site Supervisor 9.0 Air Monitoring: If, in the opinion of the site supervisor, petroleum hydrocarbon vapor concentrations are excessive, site activities will cease until petroleum hydrocarbon vapor concentrations diminish to acceptable levels. 10.0 Equipment: X FID/PID Combustible gas indicator Interface Probe O2 meter Other 11.0 Personnel Protection Equipment: Hard hat Rubber boots Respirator X Hearing Safety glasses X Work gloves X Sun screen protection X Steel toe boots X First aid kit Repellent X Nitrile Tyvek suit X Fire extinguisher Dust mask gloves 12.0 Decontamination Procedures: (evaluate need for decon, describe procedures) Use Alconox and DI water to decontaminate WLM/IFP between gauging each well. Use new, clean bailers, gloves and string for each monitoring well during sampling. 3 13.0 Emergency Contacts: a. Local Assistance: Site Phone N/A Fire Department 911 Police 911 Ambulance 911 Water Department Sanitary Sewer Natural Gas Power Company Nearest Hospital with Emergency Room (directions attached) Name Atrium Health - Wake Forest Baptist Medical Center Address 601 North Elm Street High Point, NC 27262 Number 336-878-6000 b. National or Regional Sources of Assistance: 1) Geological Resources, Inc. (866) 744-5220 2) Chemtrec (24 Hours) (800) 424-9300 3) Bureau of Explosives (24 Hours) (888) 283-2662 4) National Response Center, NRC (800) 424-8802 (Oil/Hazardous Substances) 5) DOT, Off. Of Haz. Operations (800) 467-4922 14.0 Signatures: This plan has been reviewed by all on-site personnel and all provisions are clear (signatures required). Project Manager: Samuel L. McKay, III, GRI 10/13/21 Site Supervisor: Other personnel: 3/06/23 3/06/23 4 15.0 Amendments: a. Site Specific Health and Safety Plans are based on information available at the time of plan preparation. Unexpected conditions may arise. It is important that personal protective measures be thoroughly assessed prior to and during the planned activities. Unplanned activities and/or changes in the hazard status should initiate a review of this plan and may result in major changes to it. b. Changes in the hazard status or unplanned activities are to be submitted on “Amendment to the Site Specific Health and Safety Plan” which is included bellow. c. Amendment must be approved by the Project Manager prior to implementation of the amendment. AMENDMENT TO THE SITE SPECIFIC HEALTH AND SAFETY PLAN A. Changes in field activities or hazards: B. Proposed amendment: C. Approval: Proposed by: ___________________________________date ______________________ Approved by: ___________________________________date _____________________ Amendment number: ____________________________ Amendment effective date: _______________________ APPENDIX D Fluids Disposal Manifests APPENDIX E UVF Laboratory - Soil Analytical Results 3502 Hayes Road • Monroe, North Carolina 28110 113 West Firetower Road, Suite G • Winterville, North Carolina 28590 Phone (704) 845-4010 • (888) 870-4133 • Fax (704) 845-4012 Engineering Certification: C-2727 • Geology Certification: C-127 UVF Trilogy Analytical Report Samples Collected: March 6, 2023 Samples Analyzed: March 6, 2023 Site Name: NSC; 102 Hayden Place Site Address: 102 Hayden Place, High Point, NC 27260 GRI Project Number: 4908 March 8, 2023 Xavier T. Farmer, G.I.T. Operator Technical Procedures Calibration The UFV Trilogy has standard calibrations stored for the following analysis:  GRO  DRO  Total PAH  Target PAH  Heavy PAH Prior to use, calibration standards are used to perform a 5-point verification on the factory stored calibrations for GRO and DRO. The calibration standards used are as follows: GRO  0.5 ppm  1 ppm  3 ppm  5 ppm  10 ppm DRO  0.1 ppm  0.5 ppm  1 ppm  3 ppm  5 ppm Operation Sample Extraction  5mg of soil are weighed into a clean extraction jar  Methanol is added to the extraction jar to create a 2x or 4x dilution o 2x Dilution: 10 mL of methanol o 4x Dilution: 20 mL of methanol  The extraction jar is shaken for several minutes to thoroughly mix the soil with solvent (methanol)  The mixture is allowed to settle for several minutes  A clean syringe is used to draw liquid from the extraction jar  A clean filter is attached to the end of the syringe and the liquid dispensed through the filter into a clean test tube  This liquid is referred to as the extraction Dilution Preparation  An adjustable micropipette is used to precisely measure out the amount of extract needed for the dilution  The measured out amount of the extract is added to a clean test tube and methanol is added dilute the extract. Examples of dilutions are shown below: Extract Amount 500 μL 200 μL 100 μL 50 μL 25 μL Add Solvent to the 5 mL line 5 mL line 5 mL line 5 mL line 5 mL line 2x Extract Dilution Factor 20x 50x 100x 200x 400x 4x Extract Dilution Factor 40x 100x 200x 400x 800x Technical Procedures Sample Analyzation  The dilution is shaken to thoroughly mix, then poured into a clean glass cuvette  The desired module is inserted into the UVF Trilogy and the corresponding factory calibration is selected  “Measure Fluorescence” is pressed on the touchscreen and the reading is recorded  The reading should be between the concentrations of the calibration standards (GRO: 0.5-10 ppm; DRO 0.1-5 ppm) o Reading below the calibration standard range are recorded as below the detection limit  Detection Limit = (lower range of calibration standards range) x dilution factor (i.e. a GRO sample with a 100x dilution factor has a detection limit of 50 ppm) o Readings above the calibration standard range should be further diluted and reanalyzed o Negative readings are an indication of quenching (see below)  The reading is multiplied by the dilution factor to calculate the final concentration  Check suspected contaminated samples for quenching by running additional dilutions o According to the siteLAB Quick Reference Guide: “Quenching” can occur when the detector is swamped by too many hydrocarbons or organic interferences, producing low or negative concentrations. Test the sample at multiple dilutions to confirm results are linear and accurate.” QA/QC Method Blank  A method blank of methanol will be analyzed following calibration and following the last sample analyzed each day Duplicates  One duplicate will be analyzed for every 20 samples  The duplicate will be prepared from the extract of the sample and diluted to the same factor as the sample analyzed Project Name:Date Collected: Project Number:Date Analysed: Project Manager:Operator: Sample ID Matrix Dilution Factor x GRO Output (ppm) =GRO Value (mg/Kg) Dilution Factor x DRO Output (ppm) =DRO Value (mg/Kg) SB-1 Soil 20 0.74 14.8 20 1.14 22.8 SB-2 Soil 20 <0.5 <10 20 0.36 7.2 SB-3 Soil 20 <0.5 <10 20 0.16 3.2 SB-4 Soil 40 <0.5 <20 40 0.11 4.4 UVF Analytical Report siteLAB UVF Trilogy 3/7/2023 3/6/2023 Xavier T. Farmer NSC; 102 Hayden Place 4908 Samuel McKay Report Date: 3/8/2023 Page: 1 of 1 Page: 1 of 1