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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: $#