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HomeMy WebLinkAboutMO-29309_48472_CA_UST-61_20220511_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? (Y/N) Y Facility ID Number Incident # Risk (H,I,L,U) Confirmed GW Contamination? (Y/N)_ Date Leak Discovered 05/10/2022 Received On Received By Confirmed Soil Contamination ?(Y/N) N Comm/Non-Commercial? Comm Reported by (circle one): Phone, Fax or Report Samples Taken?(Y/N) Y Reg/Non-regulated? Reg — Region Free Product? (Y/N) N If Yes, State Greatest Thickness Not Applicable INCIDENT DESCRIPTION Incident Name: D's Express Address: 223 Cabarrus Ave W County: Cabarrus Regional Office (circle one): Asheville, ooresville Fayetteville, City/Town: Concord Zip Code: 28025 Raleigh, Washington, Wilmington, Winston- a em Latitude (decimal degrees): 35.405657N Longitude (decimal degrees) : 80.587968W 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 ❑ Other A suspected release was discovered on May 10, 2022 during UST removal activities. UST closure soil sample results for soil samples collected just above the suspected groundwater interface are currently pending. No free product was observed during the tank removal activities. ❑ Unknown Describe location: Northwest corner of residence An Initial Abatement Action Report will be prepared and submitted following receipt of the UST closure results. HOW RELEASE WAS DISCOVERED (Release code) (Check one) ❑ Release Detection Equipment or Methods x Visual/Odor ❑ Groundwater Contamination x During UST Closure ❑ Water in Tank ❑ Surface Water Contamination ❑ 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) ® Tank ❑ Spill ® Petroleum X Gasoline ❑ Diesel/Veg. Oil Blend ❑ Piping ❑ Heating Non -Petroleum g Oil ❑ Vegetable Oil 100% ❑ Dispenser ❑ Corrosion ❑ Both Other Petroleum ❑ E10 — E20 ❑ Submersible Turbine Pump ❑ Physical or Mechanical Products ❑ ❑ E21 — E84 Damage Location Metals ❑ Delivery Problem ❑ Other ❑ ❑ Install Problem (Check one) Inorganics E85 — E99 ❑ Other ❑ Other Organics ❑ Ethanol 100% Facility ❑ Unknown Other X ❑ E01 — E09 ® Unknown Residence Definitions presented on reverse Definitions presented on reverse ❑ Other 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. ommercia 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 Hidden Valley Solutions LLC Point of Contact Address Mr. Yannick Tuwamo 204 Boulder Creek Road City State Zip Code Telephone Number Kathleen GA 31047 (704) 712-0844 I UST SYSTEM OPERATOR I UST Operator/Company Address MANGIKA LLC NA I City State Zip Code Telephone Number I LANDOWNER AT LOCATION OF UST INCIDENT I Landowner Address Same as UST Owner I City State Zip Code Telephone Number I Draw Sketch of Area (showing two major road intersections) or Attach Map See Attached Person Reporting Incident S. Libbey Company Hart & Hickman, PC Telephone Number (704) 586-0007 Title Project Manager - Consultant I Address 2923 S. Tryon Street, Suite 100, Charlotte, NC 28203 Date May 11, 2022 UST Form 61 (02/08) 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 N _ y � '�•> � � RRI _ ,. lie 223 Cabarrus Ave W The Kitchen 2231. +" �1ees LaundryI Jib rews Living Center Lupita G a >. 0. #A� D Gooale Earth n Controls 8!-Electric Sly 200 ft Beverly, Trudy From: Beverly, Trudy Sent: Monday, May 16, 2022 8:23 AM To: Steve Libbey Subject: RE: [External] D's Express NOI; Concord, NC - UST-3 Received. Trudy Trudy Beverly, L.G. D IE �1 Hydrogeologist, Division of Waste Management _ North Carolina Department of Environmental Quality Q� LF Pa.rI n. of Lnorun,w 0MOT ` 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: hgps:Hdeg.nc.gov/about/divisions/waste-management/ust/ast-program INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES: httns://deu.nc. gov/about/divisions/waste-management/waste-management-rules-data/waste-management-gis-mans File Review Procedures: ht_pt s://deq.nc.gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche): htt2s://deg.nc.gov/about/divisions/waste-mana2ement/laserfiche Document Submittal & UST File Names for Laserfiche Policies: httys:Hfiles.nc.eov/nedea/Waste%2OMana2ement/DWM/UST[WhatsNew/Final-Electronic-Document-Submittal-Policy.odf https:Hfiles.nc.gov/ncdeg/Waste%2OManagement/D WM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx From: Steve Libbey [mailto:slibbey@harthickman.com] Sent: Wednesday, May 11, 2022 5:51 PM To: Beverly, Trudy <trudy.beverly@ncdenr.gov> Subject: RE: [External] D's Express NOI; Concord, NC - UST-3 CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to Report Spam. Trudy, a 24-Hour Release Notice is attached for this project. Please call me if you have any questions. Thanks, Steve Stephen Libbey, PG, Project Manager Hart & Hickman, PC 2923 S Tryon Street, Suite 100 • Charlotte, NC 28203 Direct:704-887-4606 Mobile:704-302-4404 www.harthickman.com I Im From: Beverly, Trudy <trudy.beverly@ncdenr.gov> Sent: Wednesday, April 6, 2022 6:45 AM To: Steve Libbey <slibbey@harthickman.com>; Osman, Hassan <hassan.osman@ncdenr.gov>; Randolph, Wayne <wayne.randolph@ncdenr.gov>; Strauss, Ruth <ruth.strauss@ncdenr.gov> Cc: Taraban, Ron <ron.taraban@ncdenr.gov> Subject: RE: [External] D's Express NOI; Concord, NC - UST-3 Thank you Steve. Ruth, Wayne, & Osman - Please see the attached UST-3 for D's Express located at 223 Cabarrus Avenue West, Concord, Cabarrus County (Facility ID 00-0-0000007440). Tanks are scheduled to be removed on May 9tn Trudy Trudy Beverly, L.G. Hydrogeologist, Division of Waste Management North Carolina Department of Environmental Quality amwD�E UST Section, Mooresville Regional Office C.-WNS.e 704.235.2182 (Office) Trudy. B everlygncdenr. 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:Hdcg.nc.gov/about/divisions/waste-management/ust/ast-program INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES: httDs://dea.nc. eov/about/divisions/waste-manaeement/waste-manaeement-rules-data/waste-manaeement-eis-mans File Review Procedures: hops://deq.nc. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche): hitps://deq.nc.gov/about/divisions/waste-management/laserfiche Document Submittal & UST File Names for Laserfiche Policies: htti)s:Hfiles.nc.¢ov/ncdea/Waste%2OManaizement/DWM/UST[WhatsNew/Final-Electronic-Document-Submittal-Policv.l)df https:Hfiles.nc. gov/ncdeq/Waste%2OManagementlDWM[UST/Corrective%2OAction/UST%2Ofile%20names%20for%2OLaserfiche.docx From: Steve Libbey [mailto:slibbey@harthickman.com] Sent: Tuesday, April 5, 2022 6:25 PM To: Beverly, Trudy <trudy.beverly@ncdenr.gov> Subject: [External] D's Express NOI; Concord, NC 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, the Notice of Intent (UST-3) for D's Express is attached. I was as able to move it to May 91n Thanks, Steve Stephen Libbey, PG, Project Manager Hart & Hickman, PC Id 2923 S Tryon Street, Suite 100 • Charlotte, NC 28203 Direct:704-887-4606 Mobile:704-302-4404 www.harthickman.com