NCG510390_Regional Office Historical File Pre 2018 (2)

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Group Services LLC QR
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7606 Whitehall Executive Center Drive, Ste. 800 8t�.Lr o� � o Ic
Charlotte, NC 2827
[phone] FAX [phone]
TRANSMITTAL
Mooresville Regional Office
610 East Center Avenue
Mooresville, North Carolina 2115
(704) 63-199
Attn: Mr. Edward Watson,
DATE: May 21, 2018
PROJECT:
Former Star -Brice Laundry Facility
Phillips 66 RM No. 02
5639 Statesville Road
Charlotte, North Carolina 28269
NCDEQ Incident No. 1565
E ARE SENDING YOU ❑ Attached Via
❑ 1$1 Glass Mail/UPS 2 Overnight
❑ Courier ❑ Pick-up the following items:
❑ Prints
❑ Shop Drawings
❑ Change Order
❑ Mylars
❑ Plans
❑ Samples
❑ Specifications
❑ Scope of Services
❑ Sketches
❑ Letter
❑ CD/Diskettes
El
❑ Agreement
❑ Report
® Permits
COPIES
(DATE
DESCRIPTION
1
5/21/2018
Completed Application for Permit to Construct a'Monitoring or Recovery Well
System
REMARKS:
Please contact Mr. Frans Lowman with any questions.
Sinc ly,
t°
ans Lowman, P.C.
Frans. lowman a—atcgs.com
Office: (704) 5 9-3200
Mobile: [phone]
COPY TO:
If enclosures are not as rioted, please notify us at once.

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESO IURCE,
A00ti6�*IdWFOR PERMIT TO Coa§fkdj�" moNit6AW66IR RECOVERY WE�LSY
PLEASE TYPE OR PRINT CLEARLY
In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant thereto,
application is hereby made for a permit to construct monitoring or recovery wells.
FOR OFFICE USE ONLY
I . Date: 5/21/2018
2. County: Mecklenburg PERMIT NO. UVrL o-�,Otl 401 ISSUED DATE /2,34
3� What type of well are you applying for? (monitoring or recovery): Recovery
4� Applicant: ATC on behalf of Phillips 66 Telephone: [phone]
Applicant's Mailing Address: 7606 Whitehall Executive Center Drive, #800, Charlotte NC 28273
Applicant's Email Address (if available): frans.lowman@_atcas,com
5, Contact Person (if different than Applicant): Frans Lowman Telephone: [phone]
Contact Person's Mailing Address: 7606 Whitehall Executive Center Drive. #800, Charlotte NC 28273
Contact Person's Email Address (if available): frans.lowmanOatcas.com
6. Property Owner (if different than Applicant): KEZIAH JOHNNY N Telephone:
Property Owner's Mailing Address: 5300 E WT HARRIS BLVD
Property Owner's Email Address (if available):
7� Property Physical Address (including PIN Number) 5639 STATESVILLE RD
Cit Charlotte —Count MeGklenbuLg Zip Code 28269
8. Reason for Well(s): Groundwater remediation
(ex: non -discharge permit requirements, suspected contamination, assessment, groundwater contamination, remediation, etc,)
9. Type of facility or site for which the well(s) is(are) needed: UST
(ex: non -discharge facility, waste disposal site, landfill, UST, etc.)
10. Are there any current water quality permits or incidents associated with this facility or site? If so, list permit and/or incident no(s).
NPDES General Permit# NCG51 0000 NCDEQ Incident No. 15635
11, Type of contaminants being monitored or recovered: Petroleum -related VOCs
(ex: organics, nutrients, heavy metals, etc.)
12, Are there any existing wells associated with the proposed well($)? If yes, how many? 20
Existing Monitoring or Recovery Well Construction Permit No(s).: Unknown
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Groundwater oetroleurn plume on site
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes
If yes, give distance(s): WSW-1,WSW-2-200',-WSW-3-230':WSW-4-200':WSW-5-110':WSW-6-110':WSW-7-300'
15. Well Contractor.- Carolina Soil Investiciations LLC Certification No,: 2856-A
Well Contractor Address: 132 Gurnev Rd., Olin, NC 28660
PROPOSED WELL CONSTRUCTION INFORMATION
1, As required by 15A NCAC 02C .01 05(f)(7), attach a well construction diagram of each well showing the following:
a. Borehole and well diameter e. Type of casing material and thickness
b� Estimated well depth f. Grout horizons
C. Screen intervals 9� Well head completion details
d. Sand/gravel pack intervals
Continued on Reverse

PROPOSED WELL CONSTRUCTION INFORMATION (Cont nued)
2; Number of welts to be constructed In unconsolidated S. How will the well(s) be secured? well -vault
material: 1
3. Number of weds to be constructed in bedrock 0 6, Estimated beginning construction date: 8/18
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: 3t28i18
(add answers from 2 and )
ADDITIONALI I
1. As required by 15A NCAC 02C V05( (5), attach a scaled map of the site showing the locations of the following:
a. All property boundaries, at least one of which is referenced to a minimum of two landmarks such as Identified roads,
intersections, streams, or takes within 500 Feet 1f the proposed well or well system.
b. All existing wells, identified by type of use, within 500 feet of the proposed wall or well system.
C. The proposed well or well system.
d. Any test borings within 500 feet of proposed well or well system.
e. All sources of known or potential groundwater contamination (such as septic tank systems, pesticide, chemical or fuel
storage areas, animalfeedlots as defined in G S.143-215.105(5), landfalls, or other waste disposal areas) within 500 feet
of the proposed well or well system.
SIGNATURES
The Applicant hereby agrees that the proposedwell(s) will be constructed in accordance with approved specifications and conditions of
this Well Construction Permit as regulated finder the Well Construction Standards (Title 1 A of the North Carolina Administrative Code,
be apter 2C) and accepts full responsibility for compliance with these rules
­ f c wA+r
Signature of Applicant or *Agent Title of Applicant or *Agent
✓ * it signing as Agent, attach authorization agreement stating
Prsnted name of Applicant or *Agent that you have the authority to act as the Agent.
If the property is owned y someone other than the applicant, the property owner hereby consents to allow the applicant to construct
wells as outlined in this Well Construction Permit application and that it shalt be the responsibility of the applicant to ensure that the
well(s) conform to the Well Construction Standards (Title 15A of the forth Carolina Administrative Code, Subchapter 2C).
See Attached Signed Access Agreement Johnny N. Kezlah and Frances W. Ke iah
Signature of Property Owner (if different than Applicant) Printed name of Property Owner (if different than Applicant)
DIRECTIONS
Please send the completed application to the appropriate Division of Water resources' Regional Office-,
Asheville Regional Office Raleigh Regional Office Wilmington Regional Office
2090 U.S. Highway 70 3800 Barrett Drive 127 Cardinal Drive Extension
Swanna oa, NC 28778 Raleigh, €+lC 27609 Wilmington, NC 28405
Phone: [phone] Phone: [phone] Phone: (91) 7 6-7 1
Fax: [phone] Fax: [phone] Fax [phone]
Fayetteville Regional Office Washington Regional Office Winston-Salem Regional Office
225 Breen Street, Suite 714 943 Washington Square Mail 450 W Planes Mill Road
Fayetteville, NC 8301-5094 Washington, SIC 27889 Suite 300
Phone: [phone] Phone: [phone] Winston-Salem, NC 27105
Fax: [phone] Fax: [phone] Phone: [phone]
Fax: [phone]
Mooresville Regional Offlee
610 East Center Avenue
Mooresville, NC 28115 . .
Phone. [phone]
K t
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Fax: [phone]
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FIGURE 7
WATER SUPPLY WELL LOCATION MAP (MkTc
FORMER STAR-BRITE LAUNDRY FACILITY (RM 528)
5639 STATESWILLE ROAD ASSOCIATES OF NORTH CAROUNA,P.C,
CHARLOTTE NORTH CAROLINA 28269 Charlotte, North Carolina 28217 €za4l529-3200 FAX [phone]
RMR0528-20910405 AF I BC AS SHOWN 11 28 11 089.75118.0528

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FIGURE 7
PROPOSED LOCATION - RECOVERY WELL RW-3
FORMER STAR-BRITE LAUNDRY FACILITY (RM 0528)
5639 STATEVILLE :ROAD
AWRTC
ASSOCIATES OF NORTH CAROLINA P.C.
CHARLOTTE, NORTH CAROLINA 28269
Chadota, N.11h Ca li- 28273 (704)52942D4 FAX [phone]
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RMRO528_20151125
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RECOVERY WELL RW-3 CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
LOCKABLE WELL VAULT
1
1 1 L
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L1 =
O
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L2 =
33
FT.
L3 =
35
FT.
L4 =
58
FT,
1 I I t-L_
PROPOSED R®3 WELL CONSTRUCTION
Former Starbrite Laundry
539 Statesville Road
Charlotte, North Carolina
FILE JPREP. BY REV.
FL
PROTECTIVE VAULT AND CONCRETE PAD
VALILI MATERIAL VAULT DIMENSIONS 1.5
SKIRT LENGTH 12 WBit PAD DIMENSIONS 4 fedlHEIGHT ABOVE GROUND flush
WELL CASING
1.5 feet
a
feet
MATERIAL
sch 40 PVC
DIAMETER
4 inches
JOINT TYPE
flush threaded
LENGTH
33 feet
BACKFILL AROUND CASING
MATERIAL
cement -sand grout
THICKNESS
29 feet
—-- SEAL
TYPE OF SEAL
bentonite
THICKNESS
2 feet
I FILTER PACK
TYPE OF FILTER
#2 silica sand
DISTANCE ABOVE SCREEN
2 feet
WELL SCREEN
SCREEN MATERIAL
sch 4 PVC
DIAMETER
4 inches
LENGTH
35 feet
SLOT SIZE
0.010-inches'
DEPTH TO BOTTOM OF
WELL
68 feet
® DEPTH TO BOTTOM OF
BOREHOLE
68 feet
DIAMETER OF BOREHOLE
8.25 inches I.D.
JIVATC
7606 Whitehall Executive Center Drive # 800
Charlotte, North Carolina 28273
PROJECT NO;
412012018

Megan Linder
Nationwide Right of Way,
Real Estate Services
Phillips 166 Company T
1232 Park Street, Suite 300 ?
Pasts Rabies, CA 93446
Phone, (80 ) 226- 640 �
Sets# Vr Emad
CLOSING
Ed Kuhn
1.338 Hundred Oaks Drive, Suite A
f
Charlotte,; NC 28217
C'
September 9, 2014
i'
Subject: [Jcense eement - granting access to continue various environmental
investigation and/or rernedlation activities, including„ but not limited to: periodic
monitoring, sampling, and maintenance of any previously installed :or newly
required groundwater monitoring and remedition wells; operation and
maintenance of a remediation system, with eventual system removal; and
eventual proper groundwater monitoring and remediation well abandonment.
i'
Tobin #: PRW41248 AOC Site #s 0528 Acquisition #. Ci 2
Site Address: 5639 Statesville Road, Charlotte, NC -. former Phillips Marketing Site
i'
PropertyOwner- Johnny N. Keziah<and Frances W. Kezieh
5300 East W.T. Harris Boulevard
Charlotte, NC 282.5
Telephone: [phone],(its ) 323-9957I
Property Location: SITE
Effective gate; Jute 25, 2O
Expiration Date. June 25, 2 1
P Notification: coate activities wensord
Dear Ed:
Enclosed please find a copy of the above referenced document; which has been signed by property
owners, ,granting access to perform the scope of work as referenced in the subject lime above.
Pl a rnafn Tn #ills eta for, our_ ;vet€nk fffe. As you are aware, a copy of this document is being
forwarded to Real Property :Services for tracking in Tobin and future reference.
1
Please do not hesitate to contact me at [phone] should you have any questions or concerns
regarding this agreement. Thank you.
Sincerely, °t
i
Mega Linder
Contracts ,Associate
cc. Ronda Williams, Real Property Services, via U. S. mail
Scanned and £maifd.
i;

0C Site #; 0528
Acquisition r 0528
�
LICENSE ,AG �� 4 MENT
F
THIS LICENSE AGRE JGMENI' (the "Agreement") is made as of June 25, 2014, by and between
JOHNNY N. KEZIAH and FRANCES W. KEZfAH (together "Licensor) and PHILLIPS h
CUMP ("Licensee"), Licensor and. Licensee, together, shall sometimes hereinafter be
referred to as the "Parties."
RECITAL
A. Licensor is the legal and rightful owner of a certain parcel of real property located
�
at 5 63 9 Statesville Road, Charlotte, North Carolina, further identified by the MMklenburg County
1
Assessor as Parcel No. 04119301, and also referred to as the former Phillips Marketing Site #0 2
(the "Property")
i`
B. Licensee, in cooperation with the North Carolina Department, of Environment and
Natural Resources ("NCI)E "'), now desiies, to enter the Property to continue its various
environmental investigation and/or rernediation activities, at the approximate locations shown on
the site plan labeled a "Exhibit A,"° attached hereto and incorporated herein, including but not
limited to, the following (the "Work"):i
I. Periodic monitoring, sampling, and maintenance of any previously installed or
newly required groundwater monitoring and ternediation wells;
{
2 Operation and maintenance of a renaediation system." with eventual system
removal, and
3, Eventual proper groundwater dwater monitoring and r emediation well, abandonment in
accordance with state and/or municipal protocols,
C. The Parties desire to enter into this Agreement so that the soil and/or groundwater
z
ar
can continue to be assessed and/or iemediated pursuant to environmental laws and regulations"
NOW THEREFORE,, in consideration of the granting of the foregoing, the mutual premises,
i
covenants, conditions and agreements hereinafter set forth, and other good and valuable
consideration, the receipt and adequacy of which are aclaowledged, the Parties hereby agree as
fellows,
z
1,
I. tacit of License - Licenser hereby grants to Licensee, and its employees, representatives
and/or contractors an itxevocable, non-exclusive license (the "License") to enter upon. the Property
from time to time to conduct the activities described in Recitals Paragraph B and. C above.
Further, Licensor shall cause any terrains or lessees of the Property, not a party hereto, to provide'
Licensee" including its cousultant(s) and/or contractor(s), same License. This License shall
commence oil June 25, 2014 (Effective date), and shall end on June 25 2019, unless the Pattie
agree in writing to extend the term of the License. If Licensee is required by a. government agency
to maintain a well or otherequipment on the Property beyond the term of this License, their the
License shall, on notice of such requirement to Licensor, be extended until thirty (0) days after
�
such requirement ceases. Prior to the expiration of the License, Licensee shall" at its sole cost and
expense; (a) cause any excavations to be returned to the original gradient; (b) remove all
equipment placed on the Property, (c) fill and level all ditches, ruts and depressions, if any, caused.
�
Page I of 5
License Agi eement PT.t,'_RC121� 1

:3equisition #c 0528
by the closure of the Licensee's excavation operations on the Property and (d) remove all debris
resulting therefrom.
. Compliamm with Laws - Licensee shall conduct all operations which are the subject of
this License in compliance with all federal, state, and inun cipal statutes and ordinances, and with
6
all regulations, orders, and directives of appropriate govez ` ental agencies, as such statutes,
ordinances, regulations, orders and directives now exist or provide.
. Permits - Licensee; at no cost or expense to Licensor, shall be responsible for obtaining
any and all governmental permits and approvals which may be necessary for it to conduct any t
work or activities under this Agreement, Licensor shallcoordinate and cooperate with Licensee in �
Licensee's activities to obtain all necessary govez unent'pernuts and permission&
. Liens and Claims - Licensee will .not permit any mechanics', materialn en's, or sirailar
liens or claims to stand against the Property for labor or material furnished in connection with any
work performed by Licensee under this Agreement. Upon reasonable and timely notice of any
such lien or claim delivered to Licensee by Licensor, licensee may bond and contest the validity
d the amount of such lien, but Licensee will immediately pay any judgment rendered, will pay
all proper costs and charges, and will have the lien or claim released at its sole expense
I
. Coo eration - Licensee agrees to coordinate its activities with Licensor to anuri nli e any
impairment of access by customers or business invitees of Licensor to the Property and any
inconvenience to or disruption of Licensors business on the Property,
6. In emnitY W Licensee agrees that it will; indemnify and hold Licensor harmless from and
against any claims, demands, actions, suits, judgments, losses, damages, costs, or expenses I
incurred as a result, of personal injury, property damage, civil penalties, or fives to the extent �
proximately caused ;in whole or in part by the negligent acts or omissions of Licensee or its
authorized contractors and employees in conducting the Work. However, this indemnity and hold
harmless obligation shall not apply to any such claims, demands, actions, suits, judgments, losses,
damages, costs, or expenses to the extent caused by the sole negligence, gross negligence, or
willful misconduct of Licensor This indemnity is expressly conditioned on the following:
(a) In the event Licensor shall identify any matter to which this indemnity may apply or
receive a notice or claim from any third party of such matter, it shall immediately, and in every
case within. thirty (30) days of said notice or claim., notify Licensee in writing of such amatter. !
(b) Licensor shall cooperate with Licensee by allowing Licensee, its agents,
representatives, contractors and consultants prompt and ready access to the Property for the a
purpose of investigating any matter to which this indemnity may apply. Licensor shall provide
Licensee with copies of all investigative reports, data, or other information in any form, which
Licensor, its consultants or attorneys may have pertaining to any such matter, upon request of
Licensee.
r
e Notwithstanding anything in this Agreement to the contrary, in no event shall.
Licensee be liable for any special, indirect or consequential damages, including, but not limited to
Page 2 of 5
License Agreement PTRIZC12v I

AOC° 7te fir 0528
clanns for lass of use, rents, anticipated profit or business opportunity, or business interruption, or
punitive darnages or exemplary damages.
{
7. everal iti - In case any one or n ore of the provisions contained in this Agreement shall
be invalid, illegal or unenforceable in any respect, the validity, legality, and enforceability of the
iernaining provisions contained herein shall not in any way be affected or impaired thereby.
8. Notices - Any notice provided for herein or otherwise required to be given hereunder shall
be deemed received when personally served or three (3) days after inailing by certified or
registered United States mail, return receipt requested, postage prepaid, or by facsimile machine,
with transmission, and zeceipt confirmed, or by :nationally recognized overnight delivery service,
addressed as follows;
To, Licensor: Johnny IDS. Keziah and Frances W.:. iah
5300 Bast W.T.Harris Boulevard
Charlotte, lilt; 28215
Telephone: (7q f )J 3 7 -
` Facsimile: ) W14 -" t �'
To License Phillips 66 Company `
1232 Park Street, Suite 300
Paso Robles, CA 93446
Attention: Colleen Hageman
Telephone: (05) 6- 64
Facsimile- (5) 3 -441t
With Copies to- Phillips 66 Company
c/o Steve l:e in g
420 South l .eeles, PBw1760
k
Bartlesville, OK. 74404
Attention: Ed Kuhn, Contract Program Manager
Telephone: [phone]
F acsirr i e: (64) 676W 0 7 t14
The person and the place to which notices are to be mailed may be changed by either party
by providing written notice of same to the other.
. Alsignment Y This Agreement inky not be assigned by any Party without the prior 'smitten
consent of the Gaon -assigning Party, which consent shall not be unreasonably withheld, provided,
however:
(a) licensee may assign or transfer this Agreement to a successor in interest
("Assignee" which assumes the tesponszbility of conducting the Work, without consent of
Licensor, Automatically upon such, assignment or transfer, Licensee shall be released from all
obligations and liabilities hereunder accruing aftei the effective date of such assignment or
traxasfet, hided q Assignee assumes all of the obligations and liabilities hereunder acc:ming
after the effective date of such assignment or ti ansfen
Page 3 of 3
License Agreement T CJ 2sr. 7

AOC,SIte M 6528
r#cquisrtr`mr M 0528
(b) Licensor understands and acknowledges that should Licensor assign this Agreement
to an assignee ("Licensor's Assignee') without the pricer written consent of .Licensee, acceptance
r
of this Agreement by Licensor', Assignee is with recourse to Licensor, and failure of Licensor's
Assignee to fulfill its obligations tinder this Agreement will constitute a material breach of this
Agreement by Licensor and Licensor's Assignee,
1
10. Chan e in Ownership - :Licensor shall notify Licensee of any change in Property ;
ownership within five (5) days of the close of Proper°ty's escrow or the recordation of a deed v
indicating Licensor has transferred the Property to another person(s) or entity(ies) by providing
Licensee at a minimum, the new Property owner's name and contact information. Should Licensor
fail to notify Licensee of Licensor's transfer of the Property, Licensor agrees to indemnify
Licensee for any cause of action asserted against Licensee for trespass to the Property.
11, Governing Law - This Agreement shall be construed and interpreted and governed by and
in accordance with the local law of the State of North Carolina without reference to any choice of
law, rules or policies which may refer the resolution of any dispute arising hereunder to the laws of
any other: jurisdiction.
12, Entire A reeinent - Except as expressly provided herein to the contrary, this .Agreement
represents the full, complete and entire agreement between the Parties with respect to the subject
matter hereof, and the rights and remedies of the Parties shall be solely and exclusively those
herein contained, and in lieu of any remedies otherwise available at law or in equity.
I
13. Executiott of A eerzrent Each of the undersigned hereby represents and warrants that !
they are authorized to execute this Agreement on behalf of the respective Parties to the Agreement, �
and that this Agreement, when executed by those Parties, shall become a valid and binding
obligation, enforceable in accordance with its terms. Upon execution, this Agreement shall be 1
binding as to the Patties' respective parent companies, subsidiaries, affiliates, successors; heirs and
assigns.
[REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANKIl
Page 4 of
License Agreepiew PTRRC12v t

AOCS!te#r 0528
Acquisition M 0528
14. Counterparts - This Agreement may be executed in one or more counterparts, each of
Which shall be deemed an original, and all of which, taken together, shall constitute one and the
same Agreement.
TUE PARTIE S have executed this Agreement in two (2) duplicate originals on the dates
set foi th below.
LICENSOR LICENSEE
JOIINNY N KEZLkH PMLLIPS 66 COMPANY
By: By,
Name: Bill A. Hallett
Narne:4ohnny N. Keziah
br7l
Title: hr )JvLtA Title: Attom -in-Fact
Date: -7-'q-A -141 Date:
LICENSOR,
FRANCES W. KEZUH
By: --;P
Name: Frances W. Keziah
Title:
Date: '7
Page 5 of 5
License Agreement PTRRC12v, I

FIGURE 2
a 4 pE 26 SITE MAP
FORMER STAR --@RITE LAUNDRY FACILITY (RM 0528)
5639 STATES \ALLE ROAD
CHARLOTTE, NORTIi GARC LIMA 28269
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RM I PTRRC PROJECT REQUEST & INFORMATION FORM
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SITE SPECIFIC INFORMATIO PROGRAM MANAGER INFORMATION ACC0UNTING INF0FtMATI0N
SITE f F C1P N 141 I tt31+1It+1E1itTA1 CASE d Kuhn 0 28
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628 1 'L'ra8tluntlrad Oaks
Drive, Sarre A t"`i '7vNG Oo8 (11€'28.tttt.6tM
5839 Statesville Road r Charlotte '
Dhruloftes NC 28217
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NC 28269 (704) 6-OE02 ENFii9 � �# ro-r �iuxralt # vir d far x1 nsp��
704 97S3(70d
CONSULTANT INFORMATION REGULATORY AGENCY PROJECT LOCATION
X Canine ATC � �Y ...: NCDENH IL
3 Ot
2725 E. AAt€IEyreok Rd Agency tc cat'cfn Mooresvr(le, N Load
Row h Anenct+�ya Phone [phone] e
NC 27604 Agency Contact Dan Bowser 69madeAmos AgencyEmatf nbowserra)ncdenr.any nburg
- � 919 871 02aq
LANDOWNER 1 LANDOWNER 2 (It Applicable) TENANT CONTACT (It Applicable)
w € ar y ez a an ranres
4 :, Owner #2 Name Name
�.. .. z W Kersah
s3tto E, WT Haim ONd Street Address Street Address
chatlotto City tatty
,� NC 28215 State end Zip State and Zip
P.C). € ox P O. Box
,y v PC. City & Zip P City & Zip
[phone] Phone Phone
Contact Thru Contact Thru
Can Premises? On premises'?, Can Premises?
LANDOWNER ATTORNEY (It nppttearrtel PROPERTY MANAGEMENT (it Apprt aura) PTRRC CONTACT
Law Office Company � � �r � ' Megan tender
7:
Attorney Contact Name � � �������;f��; � (eas) 226-2646
Street Address Street Address Colleen ttagemann
City City Office Cltyl tate �PasoRobles
State and Zip State and Zip _ Rhone (arts) 226-2649
Phone Phone P66 Legal l Contact Sleue'Shoot
WORK DESCRIPTION ACCESS SCOPE PROJECT INFORMATION
Acres4Re<tricttanst)etaa.
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REPORT SUBMITTAL RE LiIFBEM NTS AGREEMENT INFO (ilt trC AFTER CLOSING)PRE-NOTIFICATION RE IMN7S
Frequency Agreement Bate 667.512014 In Advance
Type To §Iitlrom,i r 4 Y Agrnt Expire Crate sr26t2n19 When i
Access Fee INIA To Whom
Other i Fee Frequency N/A Other
Property &3t ne; N/A Form of
Tax ID # � Notification
trtetdat #r1 iittfr tt lscfrslle 31 tfrarrttt &ysEamt ihi) tcgctatar#.,r3f#e,, Lipisfd
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IR
MICHAI
Z
Water Resources S. JAY
Environmental Quality
September 27, 2017
Mr. Ed Kuhn
Phillips 66 Company
4215-1 Stuart Andrew Blvd.
Charlotte, North Carolina 28217 RE: Compliance Evaluation Inspection
Phillips Company — Former Star-Brite
NPDES Permit NCG510540
Groundwater Remediation
Mecklenburg County
Dear Mr. Kuhn,
nit.
ne- --ARA-
the inspection report.
with the permit for this facility.
reached by phone at [phone] or email [e-mail].
Sincerely,
Eciwar ' /ats( gist
Mooresville Regional Office
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ
Attachment: September 2017 Inspection Report
CC: Frans Lowman, AT C (via email)
State of North Carolina I Environmental Quality, I Water Resources I Water Quality Regional Operations
A A-- IAA--414� I G

United states Environmental Protection Agency
Form Approved,
EPA Washington, D.G. 20460
TOMB No, 2040-0057
Water Compliance Inspection Report
Approval expires8-31-98
Section A: National Data System Coding (,.e., PCS)
Transaction Code NPDES yrlmo/day inspection Type Inspector Fac Type
1 U Li S' NCG510540 111 12 17109121 �1 1$ f'l 19 r . Q�
1 LLLL_f6
Inspection
Work Days Facility Self -Monitoring Evaluation Rating B1 QA ------Reserved-_----------
67
1.0 70 ( 1 j 7 73 LL J 751��
U
10
Section B: Facility Data
Name and Location of Facility Inspected; (For Industrial Users discharging to POTW, also include
Entry Time/Date
Permit Effective Date
POTW name and NPDES permit Number)
10:OOAM 17109/21
16110/13
former Star-Brite Laundry
5639 Statesville Rd
Exit Time/Date
Permit Expiration Date
Charlotte NC 28269
11:30AM 17/09/21
20/09130
Name(s) of Onsite Representative(s)/Tities(s)/Phone and Fax Number(s)
Other Facility Data
111
Name, Address of Responsible Officialfritle/Phone and Fax Number
Contacted
Ed Kuhn,1338 Hundred Oaks Dr Charlotte NC 28217/1704-676-0502f7O46760704
No
Section C. Areas Evaluated During Inspection (Check only those areas evaluated)
® Permit Flow Measurement Operations & Maintenance RecordslReports
Self -Monitoring Program ®' Facility Site Review Effluent/Receiving Waters Laboratory
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
(See attachment summary)
Name(s) and Signature(s) of Inspector(s) Agency/OfFicelPhone and Fax Numbers Date
Edward Watson MRO GW1//
-27 ..0
Signature of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
.00

NPDES " yr/mo/day Inspection Type (Cont.)
1 NGG510540 � 12 17/09/21 17 18 t
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
Can September 21, 2017, Edward Watson of the MRO performed a compliance inspection for permit
NCC510540.
Present on site for the inspection were Frans Lowman and Joe Vickers of ATC.
The system was reviewed and found to operating within the limits of the permit.
CM records and laboratory analytical data were reviewed during the site visit.
Comments were made regarding the C.O.C. as to marking the preservation method as being
preserved on ice.
Also, there should be a year on the table for the monthly maintenance log sheet.
Overall, the facility was found to be in compliance with the permit
Page# 2

Permit: NCG510540 Owner- Facility: former Star-Brite Laundry
Inspection Date: 09,/2112017 Inspection Type: compliance, Evaluation
Permit )Los No N
(if the present permit expires in 6 months or less). Has the permittee submitted a new
application?
Is the facility as described in the permit? 0 0 1
# Are there any special conditions for the permit? ❑
Is access to the plant site restricted to the general public?
Is the inspector granted access to all areas for inspection?
r, * *r" ^,* I Ai+.* ; 14 +k� 4 -rt, ;+
1tilu U111" are "V OIZ-- a %ou" U".'> I r'�Av IV I 0vU1111 . luEvillf was resenan CA N1-
be viewed during the site visit, The permit recently renewed and Will not expired until
9/30/2020.
Flow Measurement - Effluent
Yes No NA NE
# Is flow meter used for reporting?
1:1
n
11
Is flow meter calibrated annually?
n
F1
rl
Is the flow meter operational?
ME]00
(if units are separated) Does the chart recorder match the flow meter?
11
El
0
n
Comment: The flow meter is chigged, annually. The purchase receil2t is being used as
proof calibration.
Laboratory
Les No NA NE
Are field parameters performed by certified personnel or laboratory?
0
El
©
0
Are all other parameters(excluding field parameters) performed by a certified lab?
N
D
11
Cl
# Is the facility using a contract lab?
a
D
n
F1
# Is proper temperature set for sample storage (kept at less than or equal to 6.0 degrees
M
El
Celsius)?
Incubator (Fecal Coliform) set to 44.5 degrees Celsius+/- 0-2 degrees?
El
n
a
El
Incubator (BOD) set to 20.0 degrees Celsius +/- 1 .0 degrees?
El
E-1
0
El
Comment: The C.O.C. needs to reflect the samples are being preserved on ice a a method of
preservation.
Operations & Maintenance
Yes No NA NE
Is the plant generally clean with acceptable housekeeping?
0
0
1:1
11
Does the fa6i 4 analyze process control parameters, for ex: MLSS, MCRT, Settleable
0
0
0
11
Solids, pH, DO, Sludge Judge, and other that are applicable?
Comment: General house keeping is good. The -grass around the treatment system should be being
maintained as part of the permit.
Effluent Pipe Yes No I
Pal

Permit NC 510540 owner - Facility: former Star-8fite Laundry
inspection Date: 09/21/2017 inspection Type, Compliance Evaluation
Effluent Pipe
Yes N2 NA NE
Is right of way to the outfall properly maintained?
■
p
Q
0
Are the receiving water free of foam other than trace amounts and other debris?
■
p
0
Q
If effluent (diffuser pipes are required) are they operating properly"?
13
■
' [l
Comment: ; The effluent pipe is located in the storm drain at the North end of the property,aloe
Statesville Rd: which empties into an unnamed tributary of Irwin Creep Stream Segment
11 -13-1 which is classified as class"C" within the Catawaba River Basin.
Page#
4

x
PPPPPP"'
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Fiat McCrory rory Thomas A. Reeder John S. Sku rla, III
Governor Director Secretary
NOTICE OF RENEWAL ]INTENT
[Required by 15A iCAC 2 .0t27 ; Iterm definition see 15A NCAC 0 .0103 19}1
Application for renewal of existing coverage under General lie it NCG5111C} , R
Existing Certificate ate caf Co era (CoG): I CwGS1(l�
(Please print or type)
E
1) :Flailing address of site Owner: adda-ess to which all correspondence should be mailed.)
Company Name Phillips 66 Company
Company Contact Ed Kuhn
Street Address 133 undred Oaks Drive, Suite A
City Charlotte State NC ZIP 28217
Telephone # 70 - 7 S 2 Fax # 0 -67 - 070
Cell/Mobile ## [phone] Email Ed. uhn(&contr ctor. 6mcrrm
2) location of remediation site producing discharge:
!Facility Contact See System Operator/Consultant ID Section
Street address 5639 Statesville Road
City Charlotte StateITC ZIP 2269
County Mecklenburg
Telephone ## See Sect 3 Fax # See Sect 3
Aid
) System operator / Consultant . Qf different,fr oin veer) Mister Quality
CoFrs y Name ATC Associates of North CarolinaP.C. ' rajas lrt Stron
Strut Address 7606 Whitehall Executive Center Drive, Suite 800
City Charlotte tte state NC ZIP 927 -
Cou my Mecklenburg
Telephone # 70 - 29-3200 Fax [phone]'
Etuail [e-mail]
Page l of 2 Revised 91111

pppppp� NCG510000 Renewal Applicat
4) Site ranking & ID: GW incident #: 15635
Site Ranking (zfavailable): H
Date of most recent discharge: March 11, 2016
Additional Application Requirements:
The following inforniation must be included in duplicate [original + 1 copy] with this application
it will be returned as incomplete.
Site map: Clearly showing the path of the rentediation system effluent from the site I
its discharge point
Authorization for representatives. If this application will be subinitted by a consult
engineer (or engineering firm), include documentation from the Permittee showing th"
the consultant submitting the application has been designated an Authorized
Representative of the applicant,
CERTIFICATION
I certify that I am familiar with the info Cation contained in this application and that to the best c
knowledge and belief such infortnation is true, complete, and accurate.
Printed Name of Person Signing: William Beck
Title: E Region Man e , RM&R
/1 7; - March 11,2016
(Signature of,4pplicant) (Date Signe4)
North Carolina General Statute 143-215.6 b (i) pro; i1des that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan or other documen
$26,000 or imprisonment not more than 5 years, or both, for a s
This Notice of Re'newal.LThe er fitted facili ' ahead a:
provides a punishment by a fine of not more than
a se-oarate fee.
ace under NCG5 10000.
Mail this application and one copy of the entire package to:
NC DENR / DWR / Water Quality Permitting Section
1617 Mail Set -vice Center
Raleigh, North Carolina 27699-1617
Attn: Charles Weaver
,by both. (18 U.S.C. Section
filar offense.)
Page 2 of 2
Revised 911113

pppppp,
LOwnuor w
WNIE 17 !�t45*lli 39K.WAIN 4,000
FIGUREI
51TE LOGATIbN MAO
FORM ER ST�R,-41TE tAUNDRY FAOLITY (RU 6 2
�S639 -STATESVILLE ROAD
tH*R'L0TTE, NORTH CAROLINA 28269
APPROXIMATE SCALE IN FEET
A
Tc
ww-q kc.
chwicft Nam OK4** AW o" 690-=00 FAX CA910 amk*02
A S- -S H 0 WN ' 05/2311 089. 7 5 8, 0,5 2

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_ a- FIGURE 2
SITE -MAP
FORMER STAR-BRIlE LAUNDRY P,t UTi° (RM 0528) AVffjkT
5639 STATESVILLE ROAD
CHARLOTTE, NORTH CAR LING 28269 Ploovzljn LAX
RIF
k ; .
RM W49 CL 8, AS SHCIN 12/10/13 1 11 3.T5` 8,0528

W PHILLIPS Risk Management and Remediation
Philips 66 Company
420 S. Keeler, 1670 PPEABartlesville, OK 74004
PPP
March 11, 2016
•
Dear Mr. Weaver:
Phillips 66 Company (Phillips 66) has retained ATC Associates of North Carolina, P.C. (ATC)
to provide environmental consulting services for the following sites with active groundwater
pump and treat remediation systems located within the Mooresville Regional Office jurisdiction:
NMI=
Rai -01=1
� ss
A
Please update your files as needed with with following consultant contact information:
Mr. Dave Hunter, P.G.
AT Associates of North Carolina, P.C.
7606 Whitehall Executive Center Drive, Suite 800
Charlotte, North Carolina 28273
If you have any questions, Please contact Mr. Edward M. Kuhn, Contract Program Manager for
Phillips 66 at the following address:
1338 Hundred Oaks Drive, Suite A
Charlotte, North Carolina 28217
Sincere
Mr. William Beck
East Regional Manager
Risk Management and Remediation
cc: Edward M. Kuhn, Contract Program Manager for Phillips 66
ATC Associates of North Carolina, P.C.
Mecklenburg County Department of Environmental Protection

United States Environmental Protection Agency Form Approvet
Washington, C7 C. 20460 OMB No, 2040
Water Compliance Inspection Report Approval expire
Section k National Data System Coding (i,e , PCS)
)de NPDES yr/mo/day Inspection Type Inspector
15 1 3 N00510 40 Ill 1 16/03/21 17 1LC
1 c�
� e
Lj
ark Days Facility Self -Monitoring Evaluation Rating 81 QA ---- --- _--_-__Reserved-_--
7014 I 71 72 73 74 7
t L J
Section B: Facility Data
Name and Location of Facility Inspected (Far Industrial Users discharging to POTW, also include Entry Time/Date Permit
POTW name and NPDES permit Number) 09'20AM 16/03/21
farmer Star-Brite Laundry
Exit Time/Date Permit
5639 Statesville Rd
10:20AM 16/03/21
Charlotte NC 28269
Name(s) of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s) Other Facility Data
Frans Lowman/1704-927-9700!
Name, Address of Responsible Official/Title/Phone and Fax Number
Contacted
Ed Kuhn,1338 Hundred Oaks Dr Charlotte NC 28217/f704-676-05020046760704
No
Section C: areas Evaluated During Inspection (Check only those areas evaluated)
Permit 0 Flow Measurement Operations & Maintenance ; Records/Reports
Self -Monitoring Program N Facility Site Review FffluenttReceiving Wafers Laboratory
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
{See attachment summary}
Name(s) and Signature(s) of Inspector(s) Agency/Office/Phone and Fax Numbers
Edward Watson MRO GW//1
Ori A Tuvia MRO WQ/f704-663-1699/
Signature of Management Q A Reviewer" Agency/Office/Phone and Fax Numbers Date
W. Carey Basinger MRO WQ//704-235-21941
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete,

NPDES yr/mo/day Inspection Type 1
31 NCG610540 � � 121 16/03/21 � 17 18 t
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
Notes by Ed Watson:
The system is .secured, clean and well kept. The equipment is in good repair and operational,
The system is supplied by two Recovery Wells (RWs) that transfer influent water to the remediation
system through a trenched network. Inspection of the RWs revealed there is a need for maintenance to
be performed on both recovery wells.
Page# 2

pppppr,
Permit: NCG510540Owner-Facility: former Star-Brite Laundry
Inspection Date: 03/21/2016 Inspection Type: Compliance Evaluation
Permit Yes No NA NE
(If the present permit expires in months or less). Has the perrnittee submitted a new M El ❑ ❑
application?
Is the facility as described in the permit? ❑ Cj ❑
Are there any special conditions for the permit? 1:1 a ❑ ❑
Is access to the plant site restricted to the general public? 0 0 ❑ ❑
Is the inspector granted access to all areas for inspection? 0 ❑ 13 13
Comment: Permit will expire on 9/30/201 . Permit is in the process of beina renewed.
Record Keeninq Yes No NA NE
Are records kept and maintained as required by the permit? 0 ❑ ❑
Is all required information readily available, complete and current? ❑
Are all records' maintained for 3 years (lab. reg. required 5 years)? M ❑ ❑ ❑
Are analytical results consistent with data reported on DMRs? ❑ ❑ M 1:1
Is the chain -of -custody complete
Dates, times and location of sampling
Name of individual performing the sampling
Results of analysis and calibration
Dates of analysis
Name of person performing analyses
Transported COCs
Are DMRs complete: do they include all permit parameters? ❑ ❑ W El
Has the facility submitted its annual compliance report to users and DWQ? ❑ ❑ M ❑
(if the facility is = or > 5 MGD permitted flow) Do they operate 4/7 with a certified operator ❑ El W ❑
on each shift?
Is the ORC visitation log available and current? ❑ U ❑
Is the ORC certified at grade equal to or higher than the facility classification? ❑ ❑ M ❑
Is the backup operator certified at one grade less or greater than the facility classification? ❑ ❑ 0 ❑
Is a copy of the current NPDES permit available on site? W ❑ ❑ 1-]
Facility has copy of previous year's Annual Report on file for review? 9 ❑ ❑[l
Comment: Records reviewed for the years 2014-2105. All records were well kept and maintained.
Chain of Custody must indicate that ice is used as a preservative for the samples that are
beinca sent for lab anal sis
LAt2rat0ry Yes No NA NE
Page#- 3

PPPPF"
Owner - Facility: former Star-Brite Laundry
Permit: NCG510540
Inspection Lute: 03/2112016 Inspection Type. Comphance Evaluation
Laboratory Yes No NA NE
Are field parameters performed by certified personnel or laboratory?
Are all other parameters(excluding field parameters) performed by a certified lab?
Is the facility using a contract lab? a 0 1:1 11
Is proper temperature set for sample storage (kept at less than or equal to 6.0 degrees 0 0 El 1:1
Celsius)?
Incubator (Fecal Coliform) set to 44.5 degrees Celsius+/- 0.2 degrees? El a 11
Incubator (BOO) set to 20.0 degrees Celsius +1- 1.0 degrees? 11 El 0 0
Comment: Lancaster tab analyzes samples.
Flow Measurement - Effluent Yes No NA
# is flow meter used for reporting
U
Is flow meter calibrated annually?
9
C3
0
[l
Is the flow meter operational'
E
El
(If units are separated) Does the chart recorder match the flow meter?
CJ
D
a
11
Comment: Flow meter last; calibrated 12/712015
Effluent Sarnpllng
Yes No NA NE
Is composite sampling flow proportional?
0
El
9
El
Is sample collected below all treatment units?
0
El
El
El
Is proper volume collected'
®
13
Is the tubing clean?
# Is proper temperature set for sample storage (kept at less than or equal to 6.0 degrees
0
El
El
0
Celsius)?
Is the facility sampling performed as required by the permit (frequency, sampling type
a
❑
11
11
representative)?
Comment: Grab sampling is required by the permit.
Effluent Moe
Yes No NA NE
Is right of way to the outfall properly maintained?
0
0
N
❑
Are the receiving water free of foam other than trace amounts and other debris?
If effluent (diffuser pipes are required) are they operating properly?
❑
D
a
11
Comment: Effluent discharge into a storm drain
C} erations & Maintenance
Yes No NA NE
Page#
4

PPFFp-
Permit: NCG510540 Owner-FacilitT former Star- Brite Laundry
inspection Date: 03/21/2016 Inspection Type: Compliance Evaluation
Operations & Maintenance Yes No NA NE
Is the plant generally clean with acceptable housekeeping? 0 El El El
Does the facility analyze process control parameters, for ex: MLSS, MCRT, Settleable F-1 D M F-1
Solids, pH, DO, Sludge Judge, and other that are applicable?
Comment: The system has two Recovery � ells.
Page# 5