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MO-30139_49195_CA_UST-61_20231014
UST-6124-Hour Release and UST Leak Reporting Form For Releases in NC 7KLVIRUPVKRXOGEHFRPSOHWHGDQGVXEPLWWHGWRWKH8676HFWLRQ¶VUHJLRQDORIILFHIROORZLQJDNQRZQRUVXVSHFWHGUHOHDVHIURPDQXQGHUJURXQGVWRUDJHWDQN867V\VWHP7KLVIRUPLVUHTXLUHGWREHVXEPLWWHGZLWKLQKRXUVRIGLVFRYHU\RID NQRZQRUVXVSHFWHGUHOHDVH ':086(21/< ,QFLGHQW 5LVN+,/8 5HFHLYHG2Q 5HFHLYHG%\ 5HJLRQ 5HSRUWHGE\circle one3KRQH(PDLORU5HSRUW 6XVSHFWHG&RQWDPLQDWLRQ"<1 1 &RQILUPHG*:&RQWDPLQDWLRQ"<1 1 &RQILUPHG6RLO&RQWDPLQDWLRQ"<1 < 6DPSOHV7DNHQ"<1 < 1$3/"<1 1 ,I<HV6WDWH*UHDWHVW7KLFNQHVV 1$ )DFLOLW\,'1$ 'DWH/HDN'LVFRYHUHG &RPP1RQ&RPPHUFLDO"1RQ&RPP 5HJ1RQUHJXODWHG"1RQUHJXODWHG ,1&,'(17'(6&5,37,21 ,QFLGHQW 1DPH0LOOHU5RDG6LWH $GGUHVV0LOOHU5RDG7D[3,1&RXQW\5RZDQ &LW\7RZQ&KLQD*URYH=LS&RGH5HJLRQDO2IILFH(circle one)$VKHYLOOH)D\HWWHYLOOH0RRUHVYLOOH 5DOHLJK:DVKLQJWRQ:LOPLQJWRQ:LQVWRQ6DOHP /DWLWXGHGHFLPDOGHJUHHV/RQJLWXGHGHFLPDOGHJUHHV/RFDWLRQ2EWDLQHGE\ %ULHIO\GHVFULEHVXVSHFWHGRUFRQILUPHGUHOHDVH:(including but not limited to: nature of release, date of release, amount of release, amount of NAPL present and recovery efforts, initial responses conducted, impacts to receptors)*36 7RSRJUDSKLFPDS 9*,6$GGUHVVPDWFKLQJ 92WKHU±*RRJOH(DUWK 8QNQRZQ 2Q2FWREHURQHDSSUR[LPDWHJDOORQKHDWLQJRLO867DVVRFLDWHGZLWKWKHVXEMHFWSURSHUW\¶VYDFDQW UHVLGHQFHZDVUHPRYHGIURPWKHJURXQG)ROORZLQJUHPRYDORIWKH867WZRVLWHFKHFNVRLOVDPSOHVZHUHFROOHFWHG IURPWKHEDVHRIWKH867SLWIRUODERUDWRU\DQDO\VLVRI'52DQG*52$OWKRXJKWKHUHZDVQRYLVXDORU3,'HYLGHQFH WKDWDUHOHDVHKDGRFFXUUHGIURPWKH867DWWKHWLPHRIUHPRYDO ODERUDWRU\DQDO\WLFDOUHVXOWVUHFHLYHGRQ 2FWREHUIRXQGWKDWRQHRIWKHWZRVLWHFKHFNVRLOVDPSOHVH[FHHGHG1&'(4¶V'52VFUHHQLQJOHYHORI PJNJZLWKDOHYHORIPJNJ7KHRWKHUVLWHFKHFNVRLOVDPSOHKDGD'52FRQFHQWUDWLRQRISSPZKLOH ERWKVLWHFKHFNVRLOVDPSOHVZHUHQRQGHWHFWIRU*522Q1RYHPEHUDULVNEDVHGVRLOVDPSOHZDV FROOHFWHGDWWKHORFDWLRQRIWKHHOHYDWHG'52FRQFHQWUDWLRQIRUODERUDWRU\DQDO\VLVRI92&V692&V0$'(393+'HVFULEHORFDWLRQ DQG0$'(3(3+$OODQDO\WLFDOUHVXOWVIRUWKHULVNEDVHGVRLOVDPSOHZHUHQRQGHWHFWZLWKWKHH[FHSWLRQRIDWUDFH DPRXQWRIPHWK\OHQHFKORULGHZKLFKLVDFRPPRQODERUDWRU\FRQWDPLQDQW 6HHDWWDFKHGPDSV +2:5(/($6(:$6',6&29(5('5HOHDVH&RGH (Check one) 5HOHDVH'HWHFWLRQ(TXLSPHQWRU0HWKRGV 'XULQJ867&ORVXUH5HPRYDO 3URSHUW\7UDQVIHU 9LVXDO2GRU :DWHULQ7DQN :DWHU6XSSO\:HOO&RQWDPLQDWLRQ *URXQGZDWHU&RQWDPLQDWLRQ 6XUIDFH:DWHU&RQWDPLQDWLRQ 92WKHUVSHFLI\6LWH&KHFN6DPSOH5HVXOWV 6285&(2)&217$0,1$7,21 6RXUFHRI5HOHDVH (Check one to indicate primary source) &DXVHRI5HOHDVH (Check one to indicate primary cause) 7\SHRI5HOHDVH (Check one) 3URGXFW7\SH5HOHDVHG (Check one to indicate primary product type released) 7DQN 3LSLQJ 'LVSHQVHU 6XEPHUVLEOH7XUELQH3XPS 'HOLYHU\3UREOHP 2WKHUVSHFLI\ 98QNQRZQ Definitions printed on reverse 6SLOO 2YHUILOO &RUURVLRQ 3K\VLFDO0HFKDQLFDO'DPDJH ,QVWDOO3UREOHP 2WKHUVSHFLI\ 98QNQRZQ Definitions printed on reverse 93HWUROHXP 1RQ3HWUROHXP %RWK *DVROLQH'LHVHO .HURVHQH 9+HDWLQJ2LO 2WKHU3HWUROHXP 3URGXFWV 0HWDOV 2WKHU,QRUJDQLFV 2WKHU2UJDQLFV 'LHVHO9HJ2LO %OHQG 9HJ2LO (±( (±( (±( (WKDQRO (±( /RFDWLRQ (Check one) )DFLOLW\ 95HVLGHQFH 2WKHU 2ZQHUVKLS 0XQLFLSDO0LOLWDU\8QNQRZQ 3ULYDWH )HGHUDO &RXQW\6WDWH 2SHUDWLRQ7\SH 3XEOLF6HUYLFH$JULFXOWXUDO5HVLGHQWLDO (GXFDWLRQ5HOLJ ,QGXVWULDO &RPPHUFLDO 0LQLQJ 867)RUP3DJHRI ,03$&721'5,1.,1*:$7(56833/,(6 :DWHU6XSSO\:HOOV$IIHFWHG" <HV 1R 8QNQRZQ 1XPEHURI:DWHU6XSSO\:HOOV$IIHFWHG1$ :DWHU6XSSO\:HOOV&RQWDPLQDWHG(Include Users’ Names, Addresses, and Phone Numbers. Attach additional sheet if necessary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eet ESP Associates, Inc. P.O. Box 7030Charlotte, NC 28241 Phone 803.802.2440 www.espassociates.com SHEET TITLE PROJECT PROJECT NO. SCALE DRAWN BY CHECKED BY KU17.600 CD NZDATE10/11/2022 FIGURE 1USGS TOPOGRAPHIC SITE LOCATION MAPµAs Shown CHINA GROVE, NORTH CAROLINA SITE BOUNDARY UST LOCATION All locations are approximate. 140 MILLER ROAD SITE LEGEND: $# $# 140 MILLER ROAD118159 0 80 160Feet ESP Associates, Inc. P.O. Box 7030Charlotte, NC 28241 Phone 803.802.2440 www.espassociates.com SHEET TITLE PROJECT PROJECT NO. SCALE DRAWN BY CHECKED BY KU17.600 CD NZDATE10/11/2022 FIGURE 2UST LOCATION MAPµAs Shown CHINA GROVE, NORTH CAROLINA SITE BOUNDARY UST LOCATION All locations are approximate. 140 MILLER ROAD SITE LEGEND: $#