MO-29309_48472_CA_UST-61_20220511_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)_
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
[phone]
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 [phone]
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

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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:[e-mail]]
Sent: Wednesday, May 11, 2022 5:51 PM
To: Beverly, Trudy <[e-mail]>
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:[phone]
www.harthickman.com I Im

From: Beverly, Trudy <[e-mail]>
Sent: Wednesday, April 6, 2022 6:45 AM
To: Steve Libbey <[e-mail]>; Osman, Hassan <[e-mail]>; Randolph, Wayne
<[e-mail]>; Strauss, Ruth <[e-mail]>
Cc: Taraban, Ron <[e-mail]>
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:[e-mail]]
Sent: Tuesday, April 5, 2022 6:25 PM
To: Beverly, Trudy <[e-mail]>
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:[phone]
www.harthickman.com