AS-2955_28198_CA_UST-3_20231103

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)
Speedway, LLC
Facility Name or Company
Speedway 7914
Street Address
500 Speedway Drive
Facility ID # (If known)
0-007592
City
Enon
County Street Address
648 Hendersonville Road
State
OH
Zip Code
45323 CityAsheville CountyBuncombe Zip Code28803-2849
Phone Number
[phone]
Email
[e-mail] Phone Number
III. CONTACT PERSONNEL
Name:
Andrew McMillan
Company Name:
7-Eleven, Inc.
Job Title:
Gas & Env. Compliance Manager
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
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:
Mike Pavelko
Contractor Company Name:
Oscar W. Larson
Address:
1420 N.W. 23rd Avenue
City:
Ft Lauderdale
State:
FL
Zip Code:
33311
Phone No:
954-214-7528
Primary Consultant Name:
Nathan Pinsker
Primary Consultant Company Name:
AECOM Technical Services of NC, Inc
Consultant Phone No:
919-461-1559
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
01 12000 Gasoline, Gas Mix
02 12000 Gasoline, Gas Mix
03 10000 Gasoline, Gas Mix
04 10000 Dielsel, Dielsel Mix
05 10000 Kerosene
* 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: Nathan Pinsker as limited field agent for Speedway, LLC
Signature Date Signed SCHEDULED REMOVAL DATE
12/12/2023
Notify your DWM Regional Office
48 hours before this date if
scheduled removal date changes
UST-3 Rev 6/2022
11/03/2023