MO-30269_49302_CA_UST-61_20231204_709 Hawkinstown Road

UST-61 .
For Releases
in NC
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
suspected release
(DWM USE ONLY)
Incident # ________ Risk (H,I,L,U)_______
Received On ________ Received By ________
Reported by (circle one): Phone, Fax or Report
Region _______
Suspected Contamination? (Y/N) ________
Confirmed GW Contamination? (Y/N) ______
Confirmed Soil Contamination ?(Y/N) ______
Samples Taken?(Y/N) ______
Free Product? (Y/N) _____ If Yes, State Greatest
Thickness ______________
Facility ID Number ______________
Date Leak Discovered ___________
Comm/Non-Commercial? ________
Reg/Non-regulated? _____________
INCIDENT DESCRIPTION
Incident Name:
Address:County:
City/Town: Zip Code:Regional Office (circle one): Asheville, Mooresville, Fayetteville,
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): Longitude (decimal degrees) :Obtained by:
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)T GPS
T Topographic map
T GIS Address matching
T Other
T Unknown
Describe location:
HOW RELEASE WAS DISCOVERED (Release Code)
(Check one)
T Release Detection Equipment or Methods
T During UST Closure/Removal
T Property Transfer
T Visual/Odor
T Water in Tank
T Water Supply Well Contamination
T Groundwater Contamination
T Surface Water Contamination
T Other (specify) _______________
SOURCE OF CONTAMINATION
Source of Release
(Check one to indicate primary
source)
Cause of Release
(Check one to indicate primary
cause)
Type of Release
(Check one)
Product Type Released
(Check one to indicate primary product type
released)
TTank
TPiping
TDispenser
TSubmersible Turbine Pump
TDelivery Problem
TOther
TUnknown
Definitions presented on reverse
TSpill
TOverfill
TCorrosion
TPhysical or Mechanical
Damage
TInstall Problem
TOther
TUnknown
Definitions presented on reverse
TPetroleum
TNon-Petroleum
TBoth
Location
(Check one)
T Facility
T Residence
T Other
T Gasoline/ Diesel/
Kerosene
T Heating Oil
T Other Petroleum
Products
T Metals
T Other Inorganics
T Other Organics
T Diesel/Veg. Oil
Blend
T Vegetable Oil 100%
T E10 – E20
T E21 – E84
T E85 – E99
T Ethanol 100%
T E01 – E09
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
Google Earth
YES N/A
NO 11/02/2023
YES COMM
YES NON REG
NO
N/A
709 Hawkinstown Road Orphan UST Releas
709 Hawkinstown Road Rowan
Salisbury 28144
-80.456324°
On 11/02/2023, during the removal of an orphan 300-gallon orphan UST, petroleum impacted soil
was observed under the tank. A total of 7.66 tons of petroleum contaminated soil were removed
from the site. Laboratory analytical results from the limits of the excavation were below the
NC Action Limits of 50 mg/kg GRO and 100 mg/kg DRO.
35.696701°
Next to Hawkinstown R
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
Point of Contact Address
City State Zip Code Telephone Number
UST SYSTEM OPERATOR
UST Operator/Company Address
City State Zip Code Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner Address
City State Zip Code Telephone Number
Draw Sketch of Area (showing two major road intersections) or Attach Map
Person Reporting Incident Company Telephone Number
Title Address Date
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
None
153 Capital, LLC
ndrew DeSorbo 567 Scaleybark Road
Charlotte NC 28209 704-724-8656
N/A Orphan UST
153 Capital, LLC 567 Scaleybark Road
Charlotte NC 28209 704-724-8656
See Attached Map
Brian Mahan Pyramid Environmental 336-335-3174
Project Manager 503 Industrial Ave.12/01/23
None
Hydrocarbon Analysis Results
Client:PYRAMID ENVIRONMENTAL Samples taken Thursday, November 2, 2023
Address GREENSORO, NC Samples extracted Thursday, November 2, 2023
Samples analysed Monday, November 6, 2023
Contact:BRIAN MAHAN Operator TORI KELLY
Project:#2023-321
13 U04049
Matrix Sample ID Dilution
used
BTEX
(C6 - C9)
GRO
(C5 - C10)
DRO
(C10 - C35)
TPH
(C5 - C35)
Total
Aromatics
C10-C35
16 EPA
PAHs BaP HC Fingerprint Match
% light % mid %
heavy
s NS 19.7 <0.49 <0.49 <0.49 <0.49 <0.1 <0.16 <0.02 0 100 0 PHC not detected
s SS 20.6 <0.52 <0.52 <0.52 <0.52 <0.1 <0.17 <0.021 0 0 0 PHC not detected,(BO)
s ES 21.0 <0.52 <0.52 <0.52 <0.52 <0.1 <0.17 <0.021 0 0 0 PHC not detected
s WS 20.3 <0.51 <0.51 <0.51 <0.51 <0.1 <0.16 <0.02 0 0 0 PHC not detected
s CS 21.0 <0.52 <0.52 <0.52 <0.52 <0.1 <0.17 <0.021 0 0 0 PHC not detected
s DS-3 21.0 <0.52 18.1 84.6 102.7 3.6 <0.17 <0.021 99 0.7 0.4 Deg.Kerosene 70.1%,(FCM)
Initial Calibrator QC check OK Final FCM QC Check OK 107.8 %
Results generated by a QED HC-1 analyser. Concentration values in mg/kg for soil samples and mg/L for water samples. Soil values are not corrected for moisture or stone content
Fingerprints provide a tentative hydrocarbon identification. The abbreviations are:- FCM = Results calculated using Fundamental Calibration Mode : % = confidence for sample fingerprint match to library
(SBS) or (LBS) = Site Specific or Library Background Subtraction applied to result : (PFM) = Poor Fingerprint Match : (T) = Turbid : (P) = Particulate present
Ratios
QED Hydrocarbon Fingerprints
Project: #2023‐321 ##################


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