The URL can be used to link to this page

Home My WebLink AboutMO-27892_47194_CA_UST 61_20200817_24-Hour Release and UST Leak Reporting FormUST 611 24-Hour Release and UST Leak Reporting Foam._,_ For Releases This form should be completed and submitted to the UST Section's regional office following a known orsuspected releasefrom an underground storage tank (UST) system. This form is required to be submitted within 24 hours of discovery of a known or in INC suspected release (DWM USE ONLY) Incident # Risk (H,I,L,U) Suspected Contamination? (Y/N) Confirmed GW Contamina8on7 (Y/N) Facility ID Number Data Leak Discovered Received On Received By Reported by (circle one): Phone, Fax or Report Confirmed Soil Contamination 7(YIN) Samples Taken?(Y Comm/Non-Commercial? of o�.� Reg/Non-regulated? Region Free Product? (Y/N) If Yes, State Greatest Thickness --� INCIDENT DESCRIPTION �/ Incident Name: Ce 0 t-& IU S AQw ( R, p r— m,d rt-uod- Address: ')-7 X7 S cLP rve k AIrise County: A4,42e �. CitylTown: /� r (D 1�1 Zip Code: 2 0� Regional Office (circle one): Ashev ll Moo Fayetteville, Raleigh, Washington, Wilmington, Wins on -Salem Latitude (dsamal/deprees): 3,5' ,`:b of L) (q Longitude (decimal degrees) : — V v7741 097 Obtained by: �PS 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 recovely efforts, Initial responses conducted, /m acts to receptors ❑ Topographic map ❑ GIS Address matching ❑ Other ❑Unknown P_% % bt5¢S 0DU wr -Alpate Rh,.PH 1t�c Qµ.psn�o.� //t� t✓1 .FGCi �/�i11>` .pp �2. 1`cin U /�4 re'(/�-•w '4 Sw� I� �,/2�� h�w" D"N4I r1 V06rsl k el Y-U21oi ( 41tc T e-U-5r f, 4-4-+- r.2a�Cs-w�r diL 4a h 1I // 1 �ff 64 -fL Rr'uLar• irJ45 Yt D'l-(,J0.�1c/ 6AT rr-...P 0t) W�o.at� Describe location: le 0 / � � C(trwEK osea Aw{c AKc� rw5 neQAb QiC IQwe o C151iet fitdc A✓, D an un04 Ilk- rf6w 4-t> btia rrCreg,v ark Aeo- i(lroKl nA-2.1a HOW RE LEASE WAS DISCOVERED (Release Code) E's'r ( 9av -l000 (Check one) 9 a / /o a r.e l e45t4 . ❑ Release Detection Equipment or Methods suall0dor ❑ Groundwater Contamination ❑ During UST Closure/Removal ❑ Water in Tank ❑ Surface Water Contamination ❑ Property Transfer ❑ Water Supply Well Contamination ❑ Other (specify) SOURCE OF CONTAMINATION Source of Release Cause of Release Tvpe 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) ,,.,� / 3/Tank El spill UIVPeVoleum Gasoline/Diesel/ ❑ DleselNeg. Oil ❑ Kerosene Blend Piping ❑ Overfill ❑ Non -Petroleum e ❑ El Heating Oil Oil 100,E ❑ Dispenser ❑ Corrosion ❑ Both ❑ Other Petroleum ❑ E10-E20 ❑ Submersible Turbine Pump ❑ Physical or Mechanical Products El E21 - E84 ElMetals ❑ Delivery Problem Damage Location ❑I Problem (Check one) ❑ Other Inorganics ❑ E85-E99 stall Other ,�❑ Other Organics ❑ Ethanol 100% &IF ❑ Unknown Other cility ❑ Unknown ❑ Residence ❑ E01 -E09 Definitions presented on reverse I Definitions resented 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. Commercial 7. Mining UST Form 61 (02/08) Page 1 of 2 IMPACT ON DRINKING WATER SUPPLIES r��-� �-.> Water Supply Wells Affected? 1. Yes 2. (NNy 3. Unknown Number of Water Supply Wells Affected NA Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet i/ necessary) 1. 2. 3. UST SYSTEM OWNER UST Owner/Core any ceo��'its e-14& jvtfdwo�d Point of Contact 1 Address / /J�l� r Otw,cee; �7a7 ✓`%ram rOCkr City F 1G � State' � 'UST Zip Code 0 XD 5' 86f TelephoneNumber - '715-,6 SYSTEM OPERATOR S UST Operator/Company Address City State Zip Code Telephone Number LANDOWNER AT LOCATION OF UST INCIDENT Landowner Address S� City State Zip Code Telephone Number Draw Sketch of Area (showing two major road intersections) or Attach Map A Person Reporting Incident ,)L„Q �,.,{ Company n I !D Telephone Number ] p el- 3 ' Title L I I Address it). 3,7 ✓.�� Ili )4070 Dateg-/] � �o 3 7 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 cease 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 nut) 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 J m m m m Ln m Figure 1 Accordius Health of Midwood 2727 Shamock Drive Charlotte, North Carolina 80.78333° W WGS84 80.766670 W r 29— E, N _:y } :�@ - _ ��`�S�e+e"K �I -i. 5 \�, ,i�f ♦ max. �/ • �?•A aiei9� allo'e ti: .'NEa}lk�uor- e 13E e Sti • r ._ A a # `4 •..I • t ktla �isr ',' I i ,=C` L �. AV 6.= - P cat' �, f -_ t vu rse � i �r•." _ I 4 a� GrahoryDr "� � � � � • � Facility Location l r rr�;�.L } ,a a . � `''� i�.f' �� rr$c �• � -- ti,�r�' � -- t BTU � a •. : q :�};;�r,•�tt t; ..'per � � ��.'' , d ry I HiKhi kilo+ _ . f • �� .. ��. � p • - _ 415. y N ♦:. T - t� p;;�� .r�� 7 �C:tscryt St ; f'il/fi r�.br � i `�� FA • � .: ��{oC1t.� f + T St rt Jeff.St )v it n$Ecr a • 1 `3--/ .- ..k,1 •. 'r• 1 SIiI r � T + m Lti I nd,or h,rr rJ G 4•'i 47 rjj � 7 ; {q` � .. � -`� ' , - � �.,; it , � ;. _.�F h•1ap°created wth "c 2010 hlational Geographic :�2007 Tele Atlas,, ReI.AA ►� Ira 30.73333' W WGS84 30.76667W 0 -5 1 MN TN NATIONALlaoo 0 1030 MIDI)m An MILES 8� GEOGRAPHIC, 0 KiLOMEFER3 FEET 1 1000 0 MEEIRS im 05/27/20 Eastway Medical Wflfuu?k r Clinic & Urgent care.. + ` Apa Nli r.- ip�� • Pik • �'� \`\ Tienda Mexicana''-'' Harne goods store F Release Location .� 'i otlrEguez Supermarket, �j,`, ' +� Metro by S-Mobile Charlotte Fire Station 5 .. 6 � Gell+ph a `tore J. At r R - xLIJr�g Van Vietnames Takeout 361 H{ a V y J, .opher the illigrapher Q: y `, s, ` 4 M l edding store r ' \ ' • . H kP • ��`�r' ►,;' + Platinum'Pressure Wash �� '� Spill Stopped �. ]Ya > Ffi?ti�� k Beverly, Trudy From: Beverly, Trudy Sent: Tuesday, August 18, 2020 10:01 AM To: steve@lighthousetechcorp.com Cc: 'Smith, Ashley M.'; 'Shane Roberts' Subject: RE: [External] RE: Accordius Health at Midwood - 2727 Shamrock Drive, Charlotte Generator Release Incident #47194 has been assigned to Accordius Health of Midwood. Trudy From: Beverly, Trudy Sent: Monday, August 17, 2020 2:59 PM To: Steve@lighthousetechcorp.com Cc: 'Smith, Ashley M.' <Ashley.Smith@mecklenburgcou ntync.gov>;'Shane Roberts' <shaner@cert-usa.com> Subject: RE: [External] RE: Accordius Health at Midwood - 2727 Shamrock Drive, Charlotte Generator Release Received. Thank you Steve. Have a great day, Trudy Trudy Beverly, L.G. Hydrogeologist, Division of Waste Management Q �� North Carolina Department of Environmental Quality UST Section, Mooresville Regional Office nnrneae �rm-onment�l4ua� 704.235.2182 (Office) Trudy. B ev erly(a),ncdenr. 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: https://deq.nc.gov/about/divisions/waste-management/ust Branch's Above Ground Storage Tanks Website Address: h_ptt s:Hdec nc.gov/about/divisions/waste-management/ust/ast-program INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES: httns://dea.nc. eov/about/divisions/waste-management/waste-manaeement-rules-data/waste-management-eis-mans File Review Procedures: hns://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/ncdeci/Waste%2OManaizement/DWM/UST[WhatsNew/Final-Electronic-Document-Submittal-Policv.adf https:Hfiles.nc. gov/ncdeq/Waste%2OManagement/DWM[UST/Corrective%2OAction/UST%2Ofile%20names%20for%2OLaserfiche.docx From: steve@lighthousetechcorp.com[mailto:steve@lighthousetechcorp.com] Sent: Monday, August 17, 2020 2:53 PM To: Beverly, Trudy <trudy.beverly@ncdenr.gov> Cc: 'Smith, Ashley M.' <Ashley.Smith@mecklenburgcountync.gov>;'Shane Roberts' <shaner@cert-usa.com> Subject: [External] RE: Accordius Health at Midwood - 2727 Shamrock Drive, Charlotte Generator Release - External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to m nc. ov Hi Trudy The UST 61 is attached. I will finish the report soon on this one. All site excavation and sampling is done for now. Some site restoration work is needed. Steve Steven B. Lucas, L.G. Environmental Geologist Lighthouse Technical, P.C. PO Box 1379 Huntersville, North Carolina 28070 704-237-4209 Office 704-439-7439 Cell www.IiRhthousetechcoro.com From: Beverly, Trudy <trudy.beverly@ncdenr.gov> Sent: Thursday, August 13, 2020 11:39 AM To: Steven Lucas <steve@lighthousetechcorp.com> Cc: Smith, Ashley M. <Ashley.Smith@mecklenburgcountync.gov>; Shane Roberts <shaner@cert-usa.com> Subject: Accordius Health at Midwood - 2727 Shamrock Drive, Charlotte Generator Release Good Morning Steve, I understand from speaking with CERT (Shane Roberts) that you are on vacation. When completed, please email the UST-61 reporting form and clean up report for this release. Thank you and have a great day, Trudy D-�E fH 'SAC IFd4 rhna�R t74 Ou�lr�� Trudy Beverly, L.G. Hydrogeologist, Division of Waste Management North Carolina Department of Environmental Quality UST Section, Mooresville Regional Office 704.235.2182 (Office) Trudy. B everly(a) ncdenn 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: https://deg.nc.gov/about/divisions/waste-management/ust Branch's Above Ground Storage Tanks Website Address: https://deg.nc.gov/about/divisions/waste-management/ust/ast-program INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES: https://deo.nc. gov/about/divisions/waste-management/waste-management-rules-data/waste-management-gis-mans File Review Procedures: https://deg.nc. gov/about/divisions/waste-manaaement/ust/file-review-procedures#mooresville-regional-office ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche): https://deq.nc.gov/about/divisions/waste-management/laserfiche Document Submittal & UST File Names for Laserfiche Policies: https:Hflles.nc.-zov/nedea/Waste%20Manap-ement/DWM/UST[WhatsNew/Final-Electronic-Document-Submittal-Policv.pdf https:Hfiles.nc. gov/ncdeq/Waste%20Management/D WM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfi che.docx