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Home My WebLink AboutWI-29575_00000_CA_20-DAY_20220930 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 Leslie Maxtone-Graham Administrative Assistant Enclosure Cc: Mr. Hisham Alsaede; T’s Food Mart & Grill LLC, file September 30, 2022 Ms. Liz Price NCDEQ-UST Section Wilmington Regional Office 127 Cardinal Drive Extension Wilmington, NC 28405 Re: 20-DAY Report September 2022 T’s Food Mart & Grill 717 E. Ocean Road Holly Ridge, Onslow County North Carolina Facility ID Number: 00-0-0000035287 Incident Number: Pending GRI Project Number: 6071 Dear Ms. Price, Please find enclosed the referenced report, for the above mentioned site. If you have any questions, please contact Scott Driscoll at 704-845-4010. Sincerely, Geological Resources, Inc. 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 20-Day Report September 2022 T’s Food Mart & Grill 717 E. Ocean Road Holly Ridge, Onslow County North Carolina Facility ID Number: 0-00-0000035287 Incident Number: Pending GRI Project Number: 6071 Prepared for: Mr. Hisham Alsaede T’s Food Mart & Grill LLC 717 E. Ocean Road Holly Ridge, North Carolina 28445 September 27, 2022 Scott Driscoll Project Manager William Regenthal, P.G. Project Manager _____________________________________________________________________________________ Prepared by: Geological Resources, Inc. 20-Day Report Prepared on: September 27, 2022 T’s Food Mart & Grill Project Manager: Scott Driscoll GRI Project No. 6071 ii EXECUTIVE SUMMARY T’s Food Mart & Grill is a convenience store and grill which formerly used USTs for storage and retail fuel sales. The site is located at 717 E. Ocean Road in Holly Ridge, Onslow County, North Carolina. The adjoining properties are mainly light commercial and residential. Municipal water is available to the site. The USTs at the site were contained in two UST basins. The gasoline USTs and dispensers were located north of the store building. The diesel fuel and kerosene UST basin was located south of the store building and their associated dispensers were located on the left front corner of the store building. The USTs were removed from the site on September 20 and 21, 2022. Ground water was encountered in the UST basin excavations at a depth of 5 feet BGS. UST closure soil samples were collected along the sidewalls of the UST basin excavations, beneath the product piping and beneath each dispenser. Collected soil samples were submitted for on-site analysis for TPH-GRO and TPH- DRO using a mobile UVF laboratory. Petroleum impacted soil above the RALs was observed beneath the kerosene and diesel dispensers. Over excavation of petroleum impacted soil was not conducted due to the proximity of the diesel and kerosene dispenser islands to the store building. No additional soil was removed from the site. Ground water monitoring well installation is warranted in each UST basin for this incident. Additional information will be included in the IAAR. _____________________________________________________________________________________ Prepared by: Geological Resources, Inc. 20-Day Report Prepared on: September 27, 2022 T’s Food Mart & Grill Project Manager: Scott Driscoll GRI Project No. 6071 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 IAAR: Initial Abatement Action Report 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. 20-Day Report Prepared on: September 27, 2022 T’s Food Mart & Grill Project Manager: Scott Driscoll GRI Project No. 6071 TABLE OF CONTENTS SITE INFORMATION ............................................................................................................................ i EXECUTIVE SUMMARY ....................................................................................................................... ii ACRONYMS ....................................................................................................................................... iii A. SITE HISTORY AND CHARACTERIZATION ...................................................................................1 B. INITIAL RESPONSE AND ABATEMENT ACTIVITIES ......................................................................2 C. SOURCE INVESTIGATION ..........................................................................................................3 D. SUMMARY AND CONCLUSIONS ................................................................................................4 E. LIMITATIONS ...........................................................................................................................5 FIGURES Figure 1: Site Location Map Figure 2: Site Map Figure 3: Soil Sample Location Map TABLES Table 1: UST Owner/Operator Information Table 2: UST System Information APPENDICES Appendix A: 24-Hour Release and UST Leak Reporting Form (UST-61) Appendix B: Notice of Intent form (UST-3) Appendix C: Site Investigation Report for Permanent Closure or Change-in-Service of UST (UST-2A) Appendix D: Health and Safety Plan ____________________________________________________________________________________________ Prepared by: Geological Resources, Inc. 20-Day Report Prepared on: September 27, 2022 T’s Food Mart & Grill Project Manager: Scott Driscoll GRI Project No. 6071 1 A. SITE HISTORY AND CHARACTERIZATION 1. UST Owner and Operator Information: In accordance with the 20-Day Report guidelines, the UST owner and operator information has been summarized in Table 1. 2. UST System Information: The UST system information has been summarized in Table 2. A copy of the Registered Tank Report is shown below: Please note, the UST ownership information does not reflect the correct current ownership of the USTs 3. Non-UST Information: No ASTs were observed on the site. 4. Comprehensive Description of the Release: GRI initiated UST closure activities at the site on September 20 and 21, 2021. The UST system consisted of two 3,000-gallon gasoline, one 1,000-gallon diesel, and one 1,000-gallon kerosene USTs, associated product piping and dispensers. Soil samples were collected from the sidewalls of the UST basin excavations, beneath the product piping and beneath each dispenser. Collected soil samples were submitted for on-site analysis for TPH-GRO and TPH-DRO using a mobile UVF laboratory. Based on the results of the soil samples collected during UST closure activities, petroleum impacted soil above the RALs was observed beneath the diesel and kerosene dispenser area. A copy of the 24-Hour UST Release ____________________________________________________________________________________________ Prepared by: Geological Resources, Inc. 20-Day Report Prepared on: September 27, 2022 T’s Food Mart & Grill Project Manager: Scott Driscoll GRI Project No. 6071 2 Reporting Form (UST Form-61) was submitted to the Wilmington regional office of NCDEQ on September 23, 2022, and is included as Appendix A. 5. Description of the Site Characteristics: The T’s Food Mart & Grill site is an active convenience store and grill which formerly used USTs for storage and retail fuel sales. The USTs were in temporary closure at the time of the removal. The site is located at 717 E. Ocean Road in Holly Ridge, Onslow County, North Carolina. The adjoining properties are mainly light commercial and residential. Municipal water is available to the site. The USTs at the site were contained in two UST basins. The gasoline USTs and dispenser island were located north of the store building. The diesel and kerosene UST basin was located south of the store building and their associated dispensers were located on the left front corner of the store building. A site map has been 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., Town of Holly Ridge for permits, Fire Marshal, and NCDEQ). A copy of the UST-3 Notice of Intent form sent to NCDEQ is included as Appendix B. The four USTs were removed from the site between September 21 and 22, 2021. Petroleum impacted soil was noted beneath the diesel and kerosene dispensers. Ground water was encountered in the UST basins at a depth of five feet BGS. A copy of the NCDEQ UST-2A form for the “Site Investigation Report for Permanent Closure or Change-in-Service of UST” has been included as Appendix C. A copy of the site- specific health and safety plan used during UST closure activities is included as Appendix D. No corrective actions were taken around or beneath the diesel and kerosene dispenser area due the proximity of the islands to the front corner of the building. B. INITIAL RESPONSE AND ABATEMENT ACTIVITIES 1. Removal of Regulated Substances from UST: Prior to the initiation of the UST closure activities the USTs were emptied; product and residual liquid were removed from the four USTs with a vacuum truck and disposed of at a permitted disposal facility. 2. Source Control Actions: The USTs, piping and dispensers were excavated and removed from the site between September 21 and 22, 2021. The USTs were in temporary closure prior to the removal. 3. Contaminant Migration Control Measures: The release was to the subsurface. No contaminant migration and control measures were necessary. 4. Measures Taken to Mitigate Fire/Safety Hazards: The town of Holly Ridge Fire Chief was notified of the removal and issued permits based upon the scope of services to be performed. Prior to removal and transport off-site, the atmosphere of each UST was checked with an LEL/02 meter; once the UST atmosphere reached less than 10% LEL, the tank was removed from the ground. There did not appear to be any immediate fire or safety hazards present as a result of the release. Photos of the USTs after the over-burden soil was removed are shown below: ____________________________________________________________________________________________ Prepared by: Geological Resources, Inc. 20-Day Report Prepared on: September 27, 2022 T’s Food Mart & Grill Project Manager: Scott Driscoll GRI Project No. 6071 3 Gasoline UST Basin Diesel/Kerosene UST Basin 3,000 Gallon Gasoline UST Diesel/Kerosene USTs 5. Measures Taken to Identify and Mitigate Pollution Hazards: The release was to the subsurface and no additional excavation of petroleum affected soil was conducted. 6. Contaminated Soil Storage/Treatment and/or Disposal: There was no impacted soil stored on or transported off site for disposal. C. SOURCE INVESTIGATION T’s Food Mart & Grill LLC contracted GRI to conduct closure activities on the four UST systems at the site. The removal activities were conducted at the site between September 19 and 21, 2022. The two 3,000- gallon USTs were in a single UST basin. The 1,000-gallon diesel and 1,000-gallon kerosene USTs were contained in a UST basin separate from the gasoline USTs. All four USTs were visually inspected and appeared to be in good condition with no obvious corrosion and pitting. The gasoline USTs were constructed of steel and measured 5.3 feet by 18 feet long. The diesel USTs was constructed of fiberglass clad steel and the kerosene UST was a STIP-3 tank. They both measured 4 feet by 12 feet in length. After removal from the ground, the USTs were transported off site for disposal. ____________________________________________________________________________________________ Prepared by: Geological Resources, Inc. 20-Day Report Prepared on: September 27, 2022 T’s Food Mart & Grill Project Manager: Scott Driscoll GRI Project No. 6071 4 During excavation activities, GRI personnel collected soil samples for on-site field screening for TPH-GRO and/or TPH-DRO using UVF technology. The on-site field screening technology was used to screen the excavated soil to determine the extent or necessity to over-excavate the UST basin and characterize overburden soil surrounding and beneath the USTs. Ground water was encountered at a depth of approximately 5 feet BGS in each UST basin, therefore soil samples were collected along the UST basin sidewalls at depths of 4 feet BGS. Samples UST-1 through UST-10 were collected from the sidewalls of the excavation dug to remove the gasoline USTs, and samples UST-11 through UST-16 were collected from the sidewalls of the excavation to remove the diesel and kerosene USTs. The facility included one gasoline dispenser, on an island located north of the store building. The diesel and kerosene UST basin was located on the south side of the store with two dispenser islands were located on the front left corner of the building facing the store from Ocean Road. Flexible non-metallic product delivery piping was used to connect all the USTs to the dispensers. Soil samples were collected along and beneath the product delivery piping at ten-foot intervals. A total of two soil samples (PP-1 and PP-2) were collected from beneath the run of gasoline piping and one soil sample (PP-3) was collected from beneath the diesel and kerosene piping. One soil sample (DI-1) was collected from beneath the gasoline dispenser. One soil sample (DI-2) was collected from beneath the kerosene dispenser. One soil sample (DI-3) was collected from beneath the diesel dispenser. The piping run and dispenser soil samples were collected at depths of two feet BGS, each. Each of the soil samples were submitted for on-site analyses of TPH-GRO and/or TPH-DRO using UVF technology. 2. Ground Water Sampling Performed to-date: Ground water was encountered in each UST basin during the removal activities; therefore, ground water monitoring well(s) will be required to be installed in each UST basin. Ground water sampling information will be presented in an IAAR D. SUMMARY AND CONCLUSIONS  The T’s Food Mart & Grill site is located in Holly Ridge, Onslow County, North Carolina. The site is an active convenience store and grill and formerly used USTs to store and resell petroleum fuels.  Two 3,000-gallon gasoline, one 1,000-gallon diesel, and one 1,000-gallon kerosene USTs were operated at the site. The USTs, dispensers and product piping were removed from the site on September 20 and 21, 2022.  UST closure soil samples were collected in accordance with NCDEQ closure guidelines along the sidewalls of the UST basins, beneath the product piping and dispensers. Collected soil samples were submitted for on-site analysis of TPH-GRO and/or TPH-DRO using a mobile UVF laboratory. ____________________________________________________________________________________________ Prepared by: Geological Resources, Inc. 20-Day Report Prepared on: September 27, 2022 T’s Food Mart & Grill Project Manager: Scott Driscoll GRI Project No. 6071 5  Petroleum impacted soil that exceeded the RALs was observed beneath the kerosene and diesel dispensers.  Ground water was encountered in the excavation area at a depth of 5 feet BGS.  Additional information will be provided in the IAAR. E. LIMITATIONS This report has been prepared for the exclusive use of T’s Food Mart & Grill LLC for specific application to the referenced site in Onslow County, North Carolina. The assessment was conducted based on the scope of work and level of effort desired by 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 are presented in this report are 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 these data. FIGURES SITE LOCATIONFigure 1 Site Location T’s Food Mart & Grill LLC717 East Ocean DriveHolly Ridge, North CarolinaOnslow CountyIncident No. 19166GRI Project No. 6071500 M2000 FTDate: 09/15/2022Location: 34.485010° N -77.554945° W Dad TABLES UST ID Number 1 and 2 Facility ID Number Owner or Operator? Owner/Operator Name of Owner or Operator Dates of Ownership / Operation TABLE 1 UST OWNER/OPERATOR INFORMATION T'S FOOD MART & GRILL (INCIDENT NO. PENDING) 00-0-0000011867 T's Food Mart & Grill LLC 08/09/2020 - Current Address Telephone Number 717 E. Ocean Road, Holly Ridge, NC 28445 910-670-8619 Page 1 of 1 Date: 09/26/22 Was Release Associated with UST System? (Yes / No) 1 Gasoline Unknown 3,000 1/1/1983 Steel 5.3' x 18'Flexible, Pressurized Removed 09/21/22 No 2 Gasoline Unknown 3,000 1/1/1983 Steel 5.3' x 18'Flexible, Pressurized Removed 09/21/22 No 3A Diesel Fuel Unknown 1,000 5/1/1998 ACT-100 4' x 12'Flexible, Pressurized Removed 09/21/22 Yes 4A Kerosene Unknown 1,000 5/1/1998 STIP-3 4' x12'Flexible, Pressurized Removed 09/21/22 Yes Tank Dimensions Description of Associated Product Piping and Pumps Status of UST TABLE 2 UST SYSTEM INFORMATION T'S FOOD MART & GRILL (INCIDENT NO. PENDING) Facility ID #: 00-0-0000035287 UST ID No. Current or Most Recent Contents Previous Contents Capacity (gallons) Date Installed Construction Details Page 1 of 1 APPENDICES APPENDIX A 24-Hour Release and UST Leak Reporting Form (UST-61) UST-61 24-Hour Release and UST Leak Reporting Form. For Releases in NC 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 suspected release (DWM USE ONLY) Incident # Risk (H,I,L,U) Received On Received By Reported by (circle one): Phone, Fax or Report Region Suspected Contamination? (Y/N) Y Confirmed GW Contamination? (Y/N) Confirmed Soil Contamination ?(Y/N) Samples Taken?(Y/N) Free Product? (Y/N)N If Yes, State Greatest Thickness Facility ID Number 0-00-0000035287 Date Leak Discovered 9/20/2022 Comm/Non-Commercial? Comm Reg/Non-regulated? Regulated INCIDENT DESCRIPTION Incident Name: T’s Food Mart & Grill Address: 717 E. Ocean Blvd County: Onslow City/Town: Holly Ridge Zip Code: 28445 Regional Office (circle one): Asheville, Mooresville, Fayetteville, Raleigh, Washington, [Wilmington], Winston-Salem Latitude (decimal degrees): 34.485044 N Longitude (decimal degrees) : 77.555065 W Obtained by: 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) GPS Soil samples collected during UST closure indicated soil impact at/beneath Topographic map the kerosene (DI-2) and diesel fuel (DI-3) island dispensers at a TPH concentration of X GIS Address matching 2,560 and 492 ppm DRO respectively. Other Unknown Describe location: Commercial/residential HOW RELEASE WAS DISCOVERED (Release Code) (Check one) Release Detection Equipment or Methods X During UST Closure/Removal Property Transfer X Visual/Odor Water in Tank Water Supply Well Contamination Groundwater Contamination Surface Water Contamination XOther (specify) UVF Soil Results SOURCE OF CONTAMINATION Source of Release (Check primary source) Cause of Release (Check primary cause) Type of Release (Check one) ( Product Type Released Check primary product type released)  Tank  Piping X Dispenser  Submersible Turbine Pump  Delivery Problem  Spill Bucket Other  Unknown Definitions presented on reverse  Spill  Overfill  Corrosion  Physical/Mechanical Damage  Install Problem  Other X Unknown Definitions presented on reverse X Petroleum  Non-Petroleum  Both Location (Check one) X Facility Residence Other X Gasoline/ Diesel/ Kero  Heating Oil  Other Petroleum Products  Metals  Other Inorganics  Other Organics  Diesel/Veg. Oil Blend  Vegetable Oil 100% E10 – E20 E21 – E84 E85 – E99 Ethanol 100% E01 – E09 Ownership 1. Municipal 2. Military 3. Unknown 4. [ Private ] 5. Federal 6. County 7. State Operation Type 1. Public Service 2. Agricultural 3. Residential 4. Education/Relig. 5. Industrial 6. [ Commercial ] 7. Mining UST Form 61 (02/19) 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 NA Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary) 1. NA 2. 3. UST SYSTEM OWNER UST Owner/Company T’s Food Mart & Grill LLC Point of Contact Mr. Hisham Alsaede Address 717 E. Ocean Blvd City Holly Ridge State NC Zip Code 28445 Telephone Number (910) 670-8619 UST SYSTEM OPERATOR Same as Owner UST Operator/Company Address City State Zip Code Telephone Number LANDOWNER AT LOCATION OF UST INCIDENT Landowner Alsaede Hisham & Kahtan Alsaidi Address 717 E. Ocean Rd City Holly Ridge State NC Zip Code 28445 Telephone Number (910) 644-2224 Draw Sketch of Area (showing two major road intersections) or Attach Map See Attachment Person Reporting Incident - Scott Driscoll Company - Geological Resources, Inc. Telephone Number 888-870-4133 Title Project Manager Address 113 W. Firetower Rd, Suite G, Winterville, NC 28590 Date 9/20/2022 UST Form 61 (02/19) 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 APPENDIX B 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. 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: City: 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. VII. OWNER OR OWNER’S AUTHORIZED REPRESENTATIVE 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 6/2022 NC Onslow NC APPENDIX C UST-2A Form - “Site Investigation Report for Permanent Closure or Change-in-Service of UST” APPENDIX D Health and Safety Plan