Haywood Co. SSOs

n
r i
This form shall be submitted to the
the sanitary sewer overflow (SSO).
E Collection S
SEP 1 4 2004
Form CS-SSO
Sanitary Sewer Overflow Reporting Form
PART I
WATER QUALITY SECTION "
ASHEVILLE REGIONAL OFFICE
within five days of the first knowledge of
Permit Number: Y eo p p (WQCS# If nctivo, othorwlso use treatment plant NC/WQ#)
Facility: 5y—r' %oc��7�.,'r1 Incident #�-
Owner: CAra/.i7o 11a7 r rv;cr- oMC. Region:
City:y//gaP a F selffor �%cir�Tgeia/ County:
Source of SSO (check applicable) : ❑ Sanitary Sewer ❑ Pump Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation - I.e. Pump Station 6,
Manhole at Westall & Bragg Street, etc.) : e<­) e-r 70-5-�97o-w en T /%srr7
Latitude (degrees/minute/second):
Incident Started Dt: .9ALoAl TimeA0,00
(mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: ��� 000 gallons
Longitude(degrees/minute/second
Incident End Dt: Cge O Time- �O-'ao
(mm-dd-yyyy) hh:mm AM/PM
Estimated Duration (Round to nearest hour): Z;-
Describe how the volume was determined: F�O� 1y6T�
Weather conditions during SSO event: 16 -,qy .Z-17G/46,5 o1' /j�6,.4
Did SSO reach surface waters? Ms ❑ No ❑ Unknown Volume reaching surface waters (gallons): �pp ooD
Surface water name:
Did the SSO result in a fish kill? ❑ Yes No ❑ Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
Severe Natural Condition
Inflow and Infiltration
❑ Vandalism
Immediate 24-hour verbal notification reported to:
X DWQ ❑ Emergency Mgmt.
❑ Grease
❑ Roots
❑ Pump Station Equipment Failure ❑ Power outage
❑ Debris in line ❑ Other (Please explain in Part II)
Date (mm-dd-yyyy): o9 Time (hh:mm AM/PM):
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail. 11
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003 Page 1

�k a Collection Systern Sanitary Sewer Overflow
l �ru:..f1Yd'tl -
•+
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN PART I OF THIS FORM
AND INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN PART I
In the check boxes below, NA = Not Applicable and NE = Not Evaluated
A HARDCOPY OF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWQ REGIONAL OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Severe Natural Condition (hurricane, tornado, etc.)
Describe the "severe natural condition" in detail.
How much advance warning did you have and what actions were taken in preparation for the event?
Comments:
Grease (Documentation such as cleaning, inspections, enforcement
actions, past overflow reports, educational material and distribution date,
etc. should be available upon request.)
When was the last time this specific line (or wet well) was cleaned?
Do you have an enforceable grease ordinance that requires new or retrofit of grease traps/interceptors?
Have there been recent inspections and/or enforcement actions taken on nearby restaurants or other
nonresidential grease contributors?
Explain.
�'7YesO No [RNA ❑NE
❑Yes❑ No;RNA❑NE
Have there been other SSOs or blockages in this area that were also caused by grease? ❑Yes❑ NON NA ❑NE
When?
If yes, describe them:
Have cleaning and inspections ever been increased at this location? ❑Yes❑ NoXNA❑NE
Explain.
CS-SSO Form October 9, 2003 Page 2

erials about grease been distributed in the past?
❑Yes No�NAONE
If the SSO occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation?
Were the floats clean? ❑YesO No ^MNA ❑ NE
Comments:
Roots
Do you have an active root control program?
Describe
❑YesE] NoireNdNAONE
Have cleaning and inspections ever been increased at this location because of roots? ❑ YeSO No X NA 0 NE
Explain:
What corrective actions have been accomplished at the SSO location (and surrounding system if
associated with the SSO)?
What corrective actions, are planned at the SSO location to reduce root intrusion?
Has the line been smoke tested or videoed within the past year? 11YesO No ® NA ❑ NE
If Yes, when?
Comments:
Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule in any permit that
addresses I/I?
❑Ye'M No11NAElNE
CS-SSO Form October 9, 2003
Page 3

Explain if Yeas:
What corrective actions have been taken to reduce or eliminate I & I related overflows at this spill location
within the last year?
Has there been any flow studies to determine 1/1 problems in the collection system at the SSO location? ❑Yes® No ❑ NA ❑ N
If Yes, when was the study completed and what actions did it recommend?
Has the line been smoke tested or videoed within the past year? ❑YesR No ❑ NA ❑ NE
If Yes, when -and indicate what actions are necessary and the status of such actions:
f.
Are there III related projects in your Capital Improvement Plan? 0 Yeslfhl No ❑NA ❑NE
If Yes, explain:
Have there been any grant or loan applications for 1/1 reduction projects? ❑Yes® No ❑ NA ❑ NE
If Yes, explain:
Do you suspect any major sources of inflow or cross connections with storm sewers? ❑Yes 19'No ❑NA ❑NE
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream been inspected recently? ®Yes❑ No ❑ NA ❑ NE
If Yes, explain:
3--eT c%He, gf? 4Jo/ked
What other.corrective actions are planned to prevent future 1/1 related SSOs at this location?
Comments:
Pump Station Equipment Failure (Documentation of testing, records etc.,
shoul be provided upon request.)
What kind of notification/alarm systems are present?
Auto-dialer/telemetry (one-way communication)
❑ Yes
CS-SSO Form October 9, 2003 Page 4

lible
lal
NDA (two-way communication)
emergency uontact bignage
Other
Describe the equipment that failed?
❑ Yes
❑ Yes
❑Yes
❑ Yes
❑ Yes
0
What kind of situations trigger an alarm condition at this station (Le. pump failure, power failure, high
water, etc.)?
Were notification/alarm systems operable? ❑Yes[] NoRNA DNE
If no, explain:
If a pump failed, when was the last maintenance and/or inspection performed?
What specifically was checked/maintained?
If a valve failed, when was it last exercised?
Were all pumps set to alternate?
Did any pump show above normal run times prior to and during the SSO event?
Were adequate spare parts on hand to fix the equipment (switch, fuse, valve, seal, etc.)?
Was a spare or portable pump immediately available?
If a float problem, when were the floats last tested? How?
If an auto -dialer or SCADA, when was the system last tested? How?
Comments:
❑YesE1 NoJ'LNJNAONE
X Yes(] No ❑ NA ❑ NE
11YesE1 NoRNAE]NE
❑ Ye,0 No � NA O NE
CS-SSO Form October 9, 2003
Page 5

Power outage (Documentation of testing, records, etc., should be
provided of alternative power source upon request.)
What is your alternate power or pumping source?
Did it function properly?
Describe?
When was the alternate power or pumping source last tested under load?
If caused by a weather event, how much advance warning did you have and what actions were taken to
prepare for the event?
Comments:
Vandalism
Provide police report number:
Was the site secured?
If Yes, how?
❑ Yes❑ No R NA ❑
❑Yes❑ No®NA❑NE
Have there been previous problems with vandalism at the SSO location? ❑YeXK No ❑ NA ❑ NE
If Yes, explain:
What security measures.have been put in place to prevent similar occurrences in the future? ❑Yes❑ NoMNA❑NE
Comments::
Debris in line (Rocks, sticks, rags and other items not allowed in the
collection system, etc.)
What type of debris has been found in the line?
How could it have gotten there?
Are manholes in the area secure and intact? X Yes[] No ❑ NA ❑ NE
CS-SSO Form October 9, 2003 Page 6

last checked/cleaned?
ning and inspections ever been increased at this location due to previous problems with debris? ❑Yes❑ NoXNA ❑NE
Are appropriate educational materials being developed and distributed to prevent future similar ❑Yes❑ No XNA ❑NE
occurrences?
Comments:
Other (Pictures and a police report should be available upon request.)
Describe:
Were adequate equipment'and resources available to fix the problem? ❑Yes❑ No ®NA ❑NE
If Yes, explain:
If the problem could not be immediately repaired, what actions were taken to lessen the impact of the
SSO?
Comments:
For DWQ Use Only:
DWQ Requested an Additional Written Report:
If Yes, What Additional Information is Needed:
Comments:
❑ Yes❑ No ❑ NA ❑ NE
CS-SSO Form October 9, 2003
Page 7

As a representative for the responsible party, I cc
to the best of my knowledge.
Person s0mitting claim:
i that the information contained in this report is true and
Signature: Title:
Telephone Number: 4;2 /89 Is -ell
Date:
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five days of first
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of this form
is completed, if used).
CS-SSO Form October 9, 2003 Page 8

This form shall be submitted to the appro
the sanitary sewer overflow (SSO).
Form CS-SSO
ry Sewer Overflow Reporting Form
PART I
days of the first knowledge of
Permit Number: NC-0oSIf 37 S' (WQCS# if active, otherwise use treatment plant NCMQ#) - -
Facility: ��'y� �' Incident #-
Owner: 'y�" L/ri�7'�c�' Region:
City: !�%/gQ� o� Scrcea�^ %y.6u�T�.'n County: A V2
Source of SSO (check applicable) : Sanitary Sewer El Pump Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation - i.e. Pump Station 6,
Manhole at Westall & Bragg Street, etc.) Tp�-
Latitude (degrees/minute/second): Longitude(degrees/minute/second)•
Incident Started Dt: Time: o6l 00 14/» 12 Incident End Dt: 0`d' 0 Time%.oD fh'/
(mm-dd-yyyy) hh:mm AM/PM (mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: Z4 noc7 gallons
Describe how the volume was determined:
Weather conditions during SSO event: /:*/ .,�-, X -ze C A
Did SSO reach surface waters? X Yes 0 No ❑ Unknown
Surface water name: 4�k X;y6"
Estimated Duration (Round to nearest hour): '-4'0'
Volume reaching surface waters (gallons):
Did the SSO result in a fish kill? Yes No Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
X Severe Natural Condition
El Inflow and Infiltration
El Vandalism
Immediate 24-hour verbal notification reported to:
X DWQ El Emergency Mgmt.
El Grease ❑ Roots
❑ Pump Station Equipment Failure ❑ Power outage
EJ Debris in line Other (Please explain in Part ll)
a 9_�
Date (mm-dd=yyyy);p �/el,7 Time (hh:mm AM/PM):,h'DD f �J
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003 Page 1

01
Collection Sytrstle Sanitary Sewer Overflow Repo
ANSWER THE FOLLOWING QUESTIONS.`FOREACHRE.UATEl3 CA dSE CHECKED IN PART I OF THIS FORM
AND INCLUDE THE APPROPRIATE �DOCUMEN� -ATfON.AS,=R:EQCJ.LRgD OR DESIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN PART I
In the.check boxes below, NA = Not Applicable and NE = Not Evaluated
A HARDCOPY OF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWQ REGIONAL OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE'REPORTING SYSTEM
Severe Natural Condition (hurricane, tornado, etc.)
Describe the "severe natural condition" in detail.
16z� X/2f.�BS of.. �s,r,%1
How much advance warning did you have and what actions were taken in preparation for the event?
Comments:
Grease (Documentation such as cleaning, inspections, enforcement
actions, past overflow reports, educational material and, distribution` date,
etc. should be available upon request.)
When was the last time this specific line (or wet well) was cleaned?
Do you have an enforceable grease ordinance that requires new or retrofit of grease traps/interceptors?
Have there been recent inspections and/or enforcement actions taken on nearby restaurants or other
nonresidential grease contributors?
Explain
❑Yes❑ NoNNA❑NE
❑ Yes❑ No ®NA ❑ NE
Have there been other SSOs or blockages in this area that were also caused by grease? ❑Yes❑ NoR NA ❑ NE
When?
If yes, describe them:
Have cleaning and inspections ever been increased at this location? ❑Yes❑ No RNA ❑ NE
Explain.
CS-SSO Form October 9, 2003 Page 2

erials about grease been distributed in the past?
If the SSO occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation?
Were the floats clean?
Comments:
Roots
Do you have'an active root control program?
❑ Yes❑ NoA NA ❑ NE
❑Yes❑ NoZNA ❑NE
❑Yes❑ No®NA❑NE
Describe
Have cleaning and inspections ever been increased at this location because of roots? ❑Yes❑ NoMNA❑NE
Explain:
What corrective actions have been accomplished at the SSO location (and surrounding system if
associated with the SSO)?
What corrective actions, are planned at the SSO location to reduce root intrusion?
Has the line been smoke tested or videoed within the past year? ❑Yes❑ No NA ❑ NE
If Yes, when?
Comments:
Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule in any permit that ❑Yes❑ No MNA ❑NE
addresses Ill?
CS-SSO Form October 9, 2003
Page 3

Explain if Yes:
What corrective actions have been taken to reduce or eliminate I & I related overflows at this spill location
within the last year?
Has there been any flow studies to determine 1/1 problems in the collection system at the SSO location? ❑Yes❑ NoJV1NA
If Yes, when was the study completed and what actions did it recommend?
Has the line been smoke tested or videoed within the past year? ❑Yes❑ No ®NA ❑NE
If Yes, when and Indicate what actions are necessary and the status of such actions:
Are there III related projects in your Capital Improvement Plan? ❑Yes❑ No0NA ❑NE
If Yes, explain:
Have there been any grant or loan applications for 1/1 reduction projects? ❑Yes❑ No ®NA FINE
If Yes, explain:
Do you suspect any major sources of inflow or cross connections with storm sewers? ❑Yes❑ No MINA ❑ NE
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream been inspected recently? ❑Yes❑ No.®NA ONE
If Yes, explain:
What other corrective actions are planned to prevent future 1/1 related SSOs at this location?
Comments:
Pump Station Equipment Failure (Documentation of testing, records etc.,
shoul be provided upon request.)
What kind of notification/alarm systems are present?
Auto-dialer/telemetry (one-way communication) El Yes
CS-SSO Form October 9, 2003 Page 4

2
)A (two-way communication)
Emergency Contact Signage
Other
Describe the equipment that failed?
❑ Yes
❑ Yes
❑ Yes
❑ Yes
❑ Yes
What kind of situations trigger an alarm condition at this station (i.e. pump failure, power failure, high
water, etc.)?
Were notification/alarm systems operable? ❑YesO No MNADNE
If no, explain:
If a pump failed, when was the last maintenance and/or inspection performed?
What specifically was checked/maintained?
If a valve failed, when was it last exercised?
Were all pumps set to alternate?
Did any pump show above normal run times prior to and during the SSO event?
Were adequate spare parts on hand to fix the equipment (switch, fuse, valve, seal, etc.)?
Was a spare or portable pump immediately available?
If a float problem, when were the floats last tested? How?
If an auto -dialer or SCADA, when was the system last tested? How?
Comments:
0Yes0 NoX NA ❑ NE
❑Yell No®NADNE
❑ Yesl No ® NA ❑ NE
DYes1_1 NoANA11NE
CS-SSO Form October 9, 2003 Page 5

Power outage (Documentation of testing, records, etc., should be
provided of alternative power source upon request.)
What is your alternate power or pumping source?
Did it function properly? ❑Yes❑ NoARVNA❑NE
Describe?
When was the alternate power or pumping source last tested under load?
If caused by a weather event, how much advance warning did you have and what actions were taken to
prepare for the event?
Comments:
Vandalism
Provide police report number:
Was the site secured?
If Yes, how?
❑Yes❑ NoMNA❑NE
Have there been previous problems with vandalism at the SSO location? ❑Yes❑ NoTNA El NE
If Yes, explain:
What security measures have been put in place to prevent similar occurrences in the future? ❑Yes❑ No ®NA ❑NE
Comments:
Debris in line. (Rocks, sticks, rags and other items not allowed in the
collection system, etc.)
What type of debris has been found in the line?
How could it have gotten there?
Are manholes in the area secure and intact? ❑Yes❑ No 9 NA❑NE
CS-SSO Form October 9, 2003 Page 6

last checked/cleaned?
and inspections ever been increased at this location due to previous problems with debris? ❑Yes❑ No56NA ❑NE
Are appropriate educational materials being developed and distributed to prevent future similar ❑Yes❑ No 0NA ❑NE
occurrences?
Comments:
Other (Pictures and a police report should be available upon requestj
Describe:
Were adequate equipment and resources available to fix the problem?
If Yes, explain:
❑ Yes❑ No CKNA ❑ NE
If the problem could not be immediately repaired, what actions were taken to lessen the impact of the
SSO?
Comments:
For DWQ Use Only:
DWQ Requested an Additional Written Report: ❑Yes❑ No ❑NA❑NE
If Yes, What Additional Information is Needed:
Comments:
CS-SSO Form October 9, 2003
Page 7

As a representative for the responsible party, I cei
to the best of my knowledge.
Person submitting claim: OAK
Signature:
Telephone Number:
(that the information contained in this report is true and A
Date:
Title:Ey
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five days of first
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of this form
is completed, if used).
CS-SSO Form October 9, 2003 Page 8

I,(tp s -C-�-
Form CSR: Collection
The Reporting form must be submitted to the DWQ Regional Office within five working days of the first
knowledge of the discharge%vee�rflow.
Permittee: 7 W �J O.7`" /" eA4-)1 1UW Facility: 440W 0-
Permit Number (WQCS# if active, otherwise use treatment plant NC/WQ#):
City: A)e�IAtv(X County: A vet' y
SPECIFI/C� location of spill/bypass (be consistent in nomenclature from past reports or documentation): MAA'�G xe5
Y0 ✓,S c44r' ;A.,
S S Y 7�c7.�-�z✓ T Gt/ G.J GtJ
Latitude/Longitude (if available):
First knowledge of incident: (Date-Mme) 5eyo /-7
Incident Ended: (Date/Time): Scp)W 7 ',�Qy)—.Estimated Duration (Time): W 1`/5
Estimated volume of spilUbypass: gallons. Show rational for volume: Q vtr ✓ 0 a 0
If spill is ongoing, please notes Regional Office on a daily basis until spill can be stopped.
Reported to: eEr �wQoergency Mgmt. (Date/time) /
Name of person
Weather conditions:
Source of spill/bypass (check one): Sani Sewer ❑ Pump Station ❑ WWTP
Level of treatment (check one): None ❑ Primary Treatment ❑ Secondary Treatment ❑ Disinfection Only
Did spilUbypass reach surface waters? es ❑ No (If Yes, please answer the following)
Volume reaching surface waters? gallons l/cP,- '5--v 0 a
Name of surface water
Did spill/bypass result in a fish kill? ❑ Yes io
If Yes, what is the estimated number of fish killed?
SPECIFIC cause of spill/bypass:
Severe Natural Condition
❑ Inflow and Infiltration
❑ Grease
❑ Vandalism
❑ Debris in line
❑ Roots
❑ Equipment failure
❑ Power outage
❑ Other uncommon event
Explain:
I certify that the information contained in this report is true and accurate to the best of my knowledge.
Person submitting report: �7 L, L�Z�, w S Date: y 0 c�

0 f \NA F9 E
4
The Director, Division of Water Quality, will take enforcement action for sanitary sewer system
discharges that required to be reported to the Division unless it is demonstrated tliat�
(1) the discharge was caused by severe natural conditions acid there were no feasible alternatives to the
discharge;
or
(2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable
control of the Permittee and/or owner, and the discharge could not have been prevented by the exercise of
reasonable control.
This form may be used to demonstrate (1) or (2) above. This claim form and'appropriate attachments should be
submitted ,to..the,Regional_-.Office alohg with,t_he Reportin.g.FonnWithin..5 ;.�orl:irb days of the date of the first
knowledge of the discharge/overflow in order to be considered for immunity from enforcement action by the
Division.
Permittee: Permit Number:
First knowledge of incident: (Date/Time) /
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN THE CSR FORM AND
INCLUDE THE APPROPRIATE DOCUMENTATION
Severe Natural Condition ( 24hr/25yr storm, hurricane, tornado, etc.)'
Describe the "severe natural condition" in detail.
Has this condition occurred in this area before? Yes R No If Yes, when?
Comments:
Inflow and Infiltration.
Are you under an SOC (Special Order by Consent) or -do you have a schedule in your permit that addresses I&I?
Yes No
Explain if Yes:
What corrective actions have been accomplished that are associated with the spill location within the last year?
What corrective actions are planned to prevent future spills at this location?
Has the line been smoked or videoed within the past year? ❑ Yes No If Yes, when?
Comments:
DRAFT CSJ Form Mav 23. 2003 DRAFT

v
r
Form CSR: Collection System Discharge/Overflow Reporting Form
(REQUIRED)
The Reporting form must be submitted to the DWQ Regional Office within five working days of the first
knowledge of the discharge%verflow.
!/ ,n
Permittee: A.,7 8' ���/ Facility:
Permit Number (WQCS# if active, otherwise use treatment plant NC/WQ#): ec-
City: Alew 6 p..;
County: 4 ver y
SPECIFIC location of spilUbypass (be consistent in nomenclature from past reports or documentation)
Latitude/Longitude (if available):
First knowledge of incident: (Date!Time) S� / 7 dd
Incident Ended: (Date/Time):/ 3h—£stimated Duration (Time):
Estimated volume of spilUbypass: gallons. Show ratiohal for volume: EycGie55
If spill is ongoing, please ^notify Regional Office on a daily basis until spill can be stopped.
Reported to: WQ ❑ Emergency Mgmt. (Date/time) /
Name of person
Weather conditions: S,eVCt^�Z;ZM�p
-Source of spill/bypass (check one): ❑ Sanitary Sewer Station WWTP
Level of treatment (check one): None ❑ Primary Treatment ❑ Secondary Treatment ❑ Disinfection Only
Did spilUbypass reach surface waters? Yes ❑ No (If Yes, please answer the -following)
Volume reaching surface waters? gallons 196
Name of surface water
Did spill/bypass result in a fish kill? ❑ Yes qto
If Yes, what is the estimated number of fish killed?
SPECIFIC cause of 7Severe
ass. Natural Condition
❑ Inflow and Infiltration
❑ Grease
❑ Vandalism
❑ Debris in line
❑ Roots
❑ Equipment failure
❑ Power outage
❑ Other uncommon event
Explain:
I certify that the information contained in this report is true and accurate to the best of my knowledge.
Person submitting report: C Lv 4ew% S Date: 9-,;to _ e q-
cxe' ' � i.4A.c�

o�0F \NArFq
T
Form CSJ: Collection
e/Overflow Justification Claim Form
The Director, Division of Water Quality, will take enforcement action for sanitary sewers stem
discharges that required to be reported to the Division unless it is demonstrated that:
(1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the
discharge; or
(2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable
control of the Permittee and/or owner, and the discharge could not have been prevented by the exercise of
reasonable control.
This form may be used to demonstrate (1) or (2) above. This claim form and'appropriate attachments should be
submitted_to.-the. Regional_..Office along-with.the R portins ;,or. .vitliin=5 vvorkir, days of the date of the first
knowledge of the discharge/overflow in order to be considered for immunity from enforcement action by the
Division. s
Permittee: Permit Number:
First knowledge of incident: (Date/Time) /
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN THE CSR FORM AND
INCLUDE THE APPROPRIATE DOCUMENTATION
Severe Natural Condition ( 24hr/25yr storm, hurricane, tornado, etc.)
Describe the "severe natural condition" in detail.
Has this condition occurred in this area before? Yes ❑ No If Yes, when?
Comments:
Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule in your permit that addresses I&I? ❑
Yes No
Explain if Yes:
What corrective actions have been accomplished that are associated with the spill location within the last year?
What corrective actions are planned to prevent future spills at this location?
Has the line been smoked or videoed within the past year? 0 Yes n No If Yes, when?
Comments:
DRAFT CSJ Form Mav 23. 2003 DRAFT

Form CSR: Collection System Discharge/Overflow Reporting Form
(REQUIRED)
The Reporting form must be submitted to the DWQ Regional Office within five working days of the first
knowledge of the discharge%verflow.
Permittee: lo(j A(j a --04 //�/ Gig-�lOt Facility: I,) w T7-p
Permit Number (WQCS# if active, otherwise use treatment plant NC/WQ#): %v G DvL f $
City: 'A J eo (41A County: A eery
SPECIFIClocation of spilVbypass (be consistent in nomenclature from past reports or documentation): Ga o-s G �4r I"cQ
Latitude/Longitude (if available):
First knowledge of incident: (Date/Timc) /'r�l 41./ 7 - ° 7A), — -
Incident Ended: (Date/Time): 567 4//1 nw-Estimated Duration (Time): 3 A 5
Estimated volume of spill/bypass: gallons. Show rational for volume: oiler 1a6. rvd a
If spill is ongoing, please notes Regional Office on a daily basis until spill can be stopped.
Reported to: j w.., j� `2 t� WQ ❑ Emergency Mgmt. (Date/time) /
Name of person
Weather conditions: se VG✓� C l,� 4 �QµJ V�¢�
Source of spill/bypass (check one): ❑ Sanitary Sewe ❑Pump Station TP
Level of treatment (check one): ❑ None rimary Treatment ❑ Secondary Treatment ❑ Disinfection Only
Did spillibypass reach surface waters? es ❑ No (If Yes, please answer the following)
Volume reaching surface waters? gallons ©YY9'- /00' a 0d 9-4- /
Name of s,--face water
Did spill/bypass result in a fish kill? ❑ Yes
If Yes, what is the estimated number of fish killed?
SPECIFIC cause of�Severe
ass: Natural Condition
❑ Inflow and Infiltration
❑ Grease
❑ Vandalism
❑ Debris in line
❑ Roots
❑ Equipment failure
❑ Power outage
❑ Other uncommon event
Explain:
1 certify that the information contained in this report is true and accurate to the best of my knowledge.
Person submitting report: ��_ �,ew ! S Date: / v2
.- - . -- .- -- -_ _ . -- 11 AA7 T" A L`T

o�0\NAr�F9oG
O�� Y
Form CSJ: Collection
e/Overflow Justification Claim Form
The Director, Division of Water Quality, will take enforcement action for sanitary sewer system
discharges that required to be reported to the Division unless it is demonstrated that:
(1) the discharge was caused by severe natural conditions aiid there -were no feasible alternatives to the
discharge;
or
(2) the discharge was exceptional, unintentional, 'temporary and.caused by factors'b'eyond-the reasonable
control of the Permittee and/or owner, and the discharge could not have been prevented by the exercise of
reasonable control.
This form may be used to demonstrate (1) or (2) above. This claim form and'appropriate attachments should be
submitted to the Regional Office along with the Reporting Forai within 5 working days of the date of the first
knowledge of the discharge/overflow in order to be considered for immunity, from enforcement action by the
Division.
Permittee::.- , z Permit Number.
First knowledge of incident: (Date/Time) /
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED'IN THE CSR FORM AND
INCLUDE THE APPROPRIATE DOCUMENTATION
Severe Natural Condition ( 24hr/25yr' storm,: hurricane, tornado,: etc.)
Describe the "severe natural condition" in detail.
Has this condition occurred in this area before? Yes n No If Yes, when?
Comments:
Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule in your permit that addresses T&I? El
Yes 0 No
Explain if Yes:
What convective actions have been accomplished that are associated with the spill location within the last year?
What corrective actions are planned to prevent future spills at this location?
Has the line been smoked or videoed within the past year? ❑ Yes No If Yes, when?
Comments:
DRAFT CSJ Form Mav 23. 2003 DRAFT

t'nse'r tj- a-s
Collection System Sanitary
This form shall be submitted to the appropriate DWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number: IVOC-5 C j i-0.-7
(WQCS# if active, otherwise use treatment plant NC/WQ#)
Facility: Incident # Z 00 g o I n 0
Owner. � ©-' C�f.✓��.�
City: —
Source of SSO (check applicable) : Sanitary Sewer
0 Pump Station
Region:
County:%'='ct��
SPECIFIC location of the SSO (be consistent in descriptiof from past reports or documentation - i e. Pump
Manhole at Westall & Bragg Street, etc.)
Latitude (degrees/minute/second):
Incident Started Dt: 07-0 i' .o % Time-
(mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: gallons
Describe how the volume was determined:
Weather conditions during SSO event —
Did SSO reach surface waters? -0 Yes
Surface water name:
Q
Long itud e(d egrees/minute/second)•
Incident End Dr 02 -ll -0 el Time- 3
(mm-dd-yyyy) hh:mm AWPM
Estimated Duration (Round to nearest hour`
1:1NoQ Unknown Volume reaching surface waters (gallons):
Did the SSO result in a fish kill? ❑ Yes ❑ No2Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC taus ) of the SSO:
Lkl Severe Natural Condition ❑ Grease ❑ Roots
❑ Inflow and Infiltration ❑ Pump Station Equipment Failure ❑ Power outage
❑ Vandalism ❑ Debris in line ❑ Other (Please explain in Part II)
Im�me late 24-hour verbal notification reported to: I<e 114,C e 1U,.4� � 1
. DWQ ❑ Emergency Mgmt. Date (mm-dd-yyyy): Time (hh:mm AM/PM):
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater.to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003 % Page 1

®�C�ZSECollection System Sanitary Se erWATER
ASHEVILLE REGIONR?ARP FI I
This form shall be submitted to the appropriate DWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number: 1416?Cs 002017 (WQCS# if active, otherwise use treatment plant NCMQ#
Facility: �'���'~' beef?fs'�� Incident#
'001-
Owner. T ei .i �,� �� ✓��� �.
Region:
City: //��✓ 114y tuvc ,i
County:
Source of SSO (check applicable) : Sanitary Sewer
SPECIFIC location of the SSO (be consistent in description from
Manhole at Westall & Bragg Street, etc.) : -2�9 S 2% q r n---'
Latitude (degrees/minute/second):
Pump Station
)ast reports or documentation - 31- i.g. ump Station 6,
Longitude (degrees/minute/second)
Incident Started Dt: 6- Old -p / Time Incident End Dt• �� "��n -(2q Tim -a IW11
(mm-dd-yyyy) hh:mm AM/PM (mm-dd-yyyy) hh:mm AWPM
Estimated volume of the SSO:
Describe how the volume was determined:
Weather conditions during SSO event
gallons Estimated Duration (Round to nearest hour):
Did SSO reach surface waters? Y-"�es❑Noll Unknown
Surface water name: '�"•�'-' ��''��" ,--,/
Did the SSO result in a fish kill? ❑ Yes ❑ No � Unknown
SPECIFIC taus of the SSO:
1(6 Severe Natural Condition ❑
❑ Inflow and Infiltration ❑
❑ Vandalism ❑
Immm ate 24-hour verbal notification reported to:
. DWQ ❑ Emergency Mgmt.
Grease
Volume reaching surface waters (gallons):
If Yes, what is the estimated number of fish killed?
Pump Station Equipment Failure
Debris in line
Date (mm-dd-yyyy):
❑ Roots
❑ Power outage
❑ Other (Please explain in Part II)
Time (hh:mm AM/PM):-
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide,a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003 Page 1

ul�t El
SEP FU t;MS
Collection System Sanitary Se er 0 erflow Reporting For
WATER QUALITY ` TJO CE
This form shall be submitted to the appropriate DWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number: (WQCS# if active, otherwise use treatment plant NC/WQ#)
Facility: r'�''� u' Sr�l' Incident # a a t^�'
Owner:
Region: /
City: ✓�r.� , — County: `y`sX'a 1
Source of SSO (check applicable) : Sanitary Sewer Pump Station
SPECIFIC location of the SSO (be consistent in description from past reports prf ocu1r entation -i.e. P mp Station 6,
Manhole at Westall & Bragg Street, etc.) : ,""'� S��Y/•�✓ �a S��y ��jf'%/ F�� O1 �r�u�`�c���
Latitude (degrees/minute/second): Lon gitude(degrees/minute/second)•
Incident Started Dt: Time, Incident End Dt• ag -/3- o5," Time 300 2,v
(mm-dd-yyyy) hh:mm AM/PM (mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: gallons Estimated Duration (Round to nearest hour)
Describe how the volume was determined:
Weather conditions during SSO event- U �� iti�•
Did SSO reach surface waters? Yes E]Non Unknown Volume reaching surface waters (gallons):
Surface water name: ��`n �^ '� Lz.4 , /
Did the SSO result in a fish kill? ❑ Yes ❑ No !f �Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cause of the SSO:
►� Severe Natural Condition ❑ Grease ❑ Roots
❑ Inflow and Infiltration ❑ Pump Station Equipment Failure ❑ Power outage
❑ Vandalism ❑ Debris in line
fj ❑ Other (Please explain in Part II)
Immediate 24-hour verbal notification reported to:
❑ . DWQ ❑ Emergency Mgmt. Date (mm-dd-yyyy): !7 --pW- 0f Time (hh:mm AM/PM):
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003 Page 1

Collection System Sanitary S
D.
SEP . 1 4 2004
Form CS -SS
e er gg
WATERQUALIT E TION
rn
ASHEVILLE REGION I E
This form shall be submitted to the appropriate DWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number: GyQC.' 06) ? Gf..)
�— (WQCS# if active, otherwise use treatment plant NC/WQ#)
Facility: ����`c� t. d )
`mo�l� -�,,.
Incident #
Owner: Tom✓ Ox,
Region:
city: LAA14 )/l/
County: ��� v.��+r/
Source of SSO (check applicable) : ❑ Sanitary Sewer
SPECIFIC location of the SSO (be consistent in description from
Manhole at Westall & Bragg Street, etc.) :�r_ r
Latitude (degrees/minute/second):1)9
—
Incident Started Dt: v `f`d
(mm-dd-yyyy)
Estimated volume of the SSO:
Time•
hh:mm AM/PM
Describe how the volume was determined:
Weather conditions during SSO event:
gallons
Did SSO reach surface waters? Id Yes ❑ No ❑ Unknown
Surface water name:'
Did the SSO result in a fish kill? ❑ Yes ❑ No 2 Unknown
SPECIFIC caus of the SSO:
Severe Natural Condition
❑ Inflow and Infiltration
❑ Vandalism
rImmediate 24-hour verbal notification reported to:
U . DWQ ❑ Emergency Mgmt.
2r—pump Station
or documentation - i.e. Pump
Longitud e(degrees/min ute/second)
Incident End Dt Time`r C�l� /fit7
(mm-dd-yyyy) hh:mm AWPM
Estimated Duration (Round to nearest hour):
Volume reaching surface waters (gallons):
If Yes, what is the estimated number of fish killed?
❑ Grease
❑ Pump Station Equipment Failure
❑ Debris in line
Date (mm-dd-yyyy):
❑ Roots
❑ Power outage
ther (Please explain in Part II)
_ _ '/•. )
Time (hh:mm AM/PM):
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of. reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003 Page 1

D
E � V E 0
�¢ 1tJjx
Q S E P. 1 4 2004
Form CS -SS
Y Collection System Sanitary Se er O r{'
WATER QUA ITY S
ASHEVILLEAEGION F CE
This form shall be submitted to the appropriate DWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number: C�
oo.(WQCS# if active, otherwise use treatment plant NCMQ#)
l� S s��
�,,�
Facility: � � � }�� Incident# -z a � � 1) j
Owner. - �� b'✓•� c� �� w ��.✓
Region: j
City: .fin-' • ✓" County: r/
Source of SSO check applicable) /
( PP ) : ❑ Sanitary Sewer � Pump Station
SPECIFIC location of the SSO (be consi%nt in description from past reports or documentationi.e. Pump Station 6,
Manhole at Westall & Bragg Street, etc.) : Yf�N ��%�i�,r.� '� r��Ji� f3�ii.�e v /3D� f�,r
Latitude (degrees/minute/second): Lon gitude(degrees/minute/second)•
Incident Started Dt: Of- 0:-0'/ Time- Incident End Dt• Or- 09 `d-'l Timea &70
(mm-dd-yyyy) hh:mm AM/PM (mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: gallons Estimated Duration (Round to nearest hour).
---
Describe how the volume was determined:
Weather conditions during SSO event: Ileltv ' ' .%' c -) ."
Did SSO reach surface waters? -Q Yes❑Noll Unknown Volume reaching surface waters (gallons):
Surface water name: r
Did the SSO result in a fish kill? ❑ Yes El.�1 No U—nknown If Yes, what is the estimated number of fish killed?
SPECIFIC caws ��fthe SSO:
'— Severe Natural Condition ❑ Grease ❑ Roots
El Inflow and Infiltration ❑ Pump Station Equipment Failure ❑ Power outage
Vandalism 13 Debris in line ❑ Other (Please explain in Part II)
I_ edd'ate 24-hour verbal notification reported to:
. DWQ ❑ Emergency Mgmt. Date
Time (hh:mm AM/PM):
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003 Page 1

S t P. l 4 2004
Form CS-SO
.:; Collection System Sanitary S wer ftecflow-Rer —
WATER-QUAL T
ASHEVILLE R_EGiONAP� i%
This form shall be submitted to the appropriate DWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit NumberJIM A tw) J (WQCS# if active, otherwise use treatment plant NC/WQ#)
Facility: %�.�'r e) ® l
Incident # (�
Owner: - "`•i'' �5��'.N1�� a/
����c�/✓ Region:
city: County: i�ltfi�✓���
Source of SSO (check applicable) : ❑ Sanitary Sewer Pump Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation - i.e. Pump Station 6,
Manhole at Westall & Bragg Street, etc.) : 'R q.
Latitude (degrees/minute/second):
Incident Started Dt: `�`����% �' Time•
(mm-dd-yyyy) hh:mm AWPM
Estimated volume of the SSO:
Describe how the volume was determined:
Weather conditions during SSO event:,
gallons
Did SSO reach surface waters? Yes❑No0 Unknown
Surface water name: ,—,/
Did the SSO result in a fish kill? ❑ Yes ❑ No ICJ Unknown
SPECIFIC cause(s) of the SSO:
Long itude(degrees/minute/secon d)-
Incident End Dt: VS't%k12L Time
(mm-dd-yyyy) hh:mm AM/PM
Estimated Duration (Round to nearest hour)= --
Volume reaching surface waters (gallons):
If Yes, what is the estimated number of fish killed?
Severe Natural Condition ❑ Grease
Inflow and Infiltration ❑ Pump Station Equipment Failure
❑ Vandalism ❑ Debris in line
Immediate 24-hour verbal notification reported to:
®. DWQ ❑ Emergency Mgmt.
lee 12 - 1114ii"tJe c
❑ Roots
❑ Power outage
❑ Other (Please explain in Part II)
Date (mm-dd-yyyy)• � _OV Time (hh:mm AM/PM):
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater.to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003 Page 1

C-E] V E D
o
FEPCS-SSO
L T,i
Collection System Sanitary Sew
ting Form
LIT
This form shall be submitted to the appropriate DWQ Regional Office within five days of REGIONAL OFFICE
the sanitary sewer overflow (SSO).
Permit Number : "i-1 SOS ti % (WQCS# if active, otherwise use treatment plant NC/INQ#L�r
Facility: ��^��� " �� C�i Incident# 0 6t'� i 4
Owner. - .`.+. n� [ 'i,�,✓�a n�
Region: ,,
City: C���cr.+_ County: 11A6 14"10-�
Source of SSO (check applicable) : ❑ Sanitary Sewer Pump Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation i.e. Pump Station 6,
Manhole at Westall & Bragg Street, etc.) :2ZPI ^-��%�Sow/
Latitude (degrees/minute/second): Longitude(degrees/minutelsecond)-
Incident Started Dt: 02'62' 42 ' ©
Time- Incident End Dt• / Time- � 00
(mm-dd-yyyy) hh:mm AM/PM (mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: gallons Estimated Duration (Round to nearest hour)----- `
Describe how the volume was determined:
Weather conditions during SSO event:� c�A vV R4 �� - ✓^
Did SSO reach surface w ters? Yes ❑ No Unknown Volume reaching surface waters (gallons):
Surface water name: /
Did the SSO result in a fish kill? El Yes El No 2-U-nknown If Yes, what is the estimated number of fish killed?
SPECIFIC cause of the SSO:
'le -severe Natural Condition ❑ Grease ❑ Roots
❑ Inflow and Infiltration ❑ Pump Station Equipment Failure ❑ Power outage
❑ Vandalism ❑ Debris in line ❑ Other ()Please explain in Part II)
Im�me late 24-hour verbal notification reported to: ���' �� ��� ✓� ��4'+ ��+.a,
. DWQ ❑ Emergency Mgmt. Date (mm-dd-yyyy):eq ? eq�& Time (hh:mm AM1PM):
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater.to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where t e discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003 Page 1

Collection System Sanitary
R
E C E� U E
S E P Form b%'!SS
ver Overflow Reporting For
WATER QUALITY
This form shall be submitted to the appropriate DWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number: �/ C�'dc�JF�
- � (WQCS# if active, otherwise use treatment plant NCMQ#)
Facility:', J7/,/ Incident # o 1-1 0 1 `f
Owner. 1 dc.✓.✓
• ���✓��° ti Region -
city.
County: fort
Source of SSO (check applicable) : ❑ Sanitary Sewer Pump Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentatign - i.e. Pump Station 6,
�Uy-.�
Manhole at Westall & Bragg Street, etc.) :
G���`-A/ 25��-✓/��✓c� S-
Latitude (degrees/minute/second):
Longitude(degrees/miinute/second)•
Incident Started Dt: O -�� !� Time-
Incident End Dt• / _6U - 02 Time ham(
(mm-dd-yyyy) hh:mm AM/PM (mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO:
gallons Estimated Duration (Round to nearest hou6; '
Describe how the volume was determined:
Weather conditions during SSO event
Did SSO reach surface waters? ❑No❑ Unknown Volume reaching surface waters (gallons):
Surface water name: T' `•
Did the SSO result in a fish kill? ❑ Yes ❑ No
2 Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cans of the SSO:
Severe Natural Condition
❑ Grease ❑ Roots
El Inflow and Infiltration
❑ Pump Station Equipment Failure ❑ Power outage
❑ Vandalism
❑ Debris in line ❑ Other (Please explain in Part 11)
Imm to 24-hour verbal notification reported to:
DWQ ❑ Emergency Mgmt.
Date (mm-dd-yyyy): pq_pp'_0/y Time (hh:mm AM/PM):
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater.to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of. reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003 Page 1

F D-1E C E V E
0
: S�� Form CS -SS
Collection System Sanitary Se vver
WATER QUALITY SECTION
ASHEVILLE REGIONF{b �I E
This form shall be submitted to the appropriate DWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number: l;(� C. �o (WQCS# if active, otherwise use treatment plant NC/WQ#)
�
Facility:Incident #
Owner: Region: r
City: �/,.. A/ County: h K 4'V iD
Source of SSO (check applicable) : -Sanitary Sewer Pump Station
SPECIFIC location of the SSO (be consistent in descrjption fro past r orts or documentation - i.e. Pump Station
Manhole at Westall & Bragg Street, etc.)
Latitude (degrees/minute/second): Longitude(degrees/minute/second)-
Incident Started Dt� -Off-"v G Time- Incident End Dt 02 - o y Time-
(mm-dd-yyyy) hh:mm AM/PM (mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: gallons Estimated Duration (Round to nearest hour;; '
Describe how the volume was determined:
Weather conditions during SSO event:���'�
Did SSO reach surface waters? 1Yes u No ❑ Unknown Volume reaching surface waters (gallons):
Surface water name: ,,��,,//
Did the SSO result in a fish kill? Yes El No � Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cause of the SSO:
Severe Natural Condition ❑ Grease ❑ Roots
Inflow and Infiltration ❑ Pump Station Equipment Failure ❑ Power outage
Vandalism ❑ Debris in line Other (Please explain in Part II)
Immediate 24-hour verbal notification reported to: - <e, 4yl—e-S
. DWQ ❑ Emergency Mgmt. Date (mm-dd-yyyy):ag-d,-tr-/ Time (hh:mm AM/PM):
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater.to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003 Page 1

¢ Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
-- PART I I
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN PART I OF THIS FORM
AND INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN PART I
In the check boxes below, NA = Not Applicable and NE = Not Evaluated
A HARDCOPY OF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWQ REGIONAL OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Severe Natural Condition (hurricane, tornado, etc.)
Describe the "severe natural condition" in detail.
How much advance warning did you have and what actions were
taken in preparation for the event?
,1
%C� i� : �n..rr_p !'' i a.�r/ fi.'�� �T�'�'Tid�/ Wt'. -,°r/ �✓/,i'c'� i�rl� ' �
Comments:
Grease (Documentation such as cleaning, inspections, enforcement
actions, past overflow reports, educational material and distribution date,
etc. should be available upon request.)
When was the last time this specific line (or wet well) was cleaned? —
Do you have an enforceable grease ordinance that requires new or retrofit of grease traps/interceptors? Yes❑ No NALINE
Have there been recent inspections and/or enforcement actions taken on nearby restaurants or other uYes[] No 0 NA ONE
nonresidential grease contributors?
Explain.
Have there been other SSOs or blockages in this area that were also caused by grease? ❑Yell No BNA ONE
When?
If yes, describe them:
Have cleaning and inspections ever been increased at this location? ❑Yes❑ No�AONE
Explain.
CS-SSO Form October 9, 2003 Page 2

Have educational materials about grease been distributed in the past?
When?
and to whom?
Explain?
❑Yes❑ No2NA❑NE
If the SSO occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation?
Were the floats clean? Yes❑ No ❑ NA ❑ NE
Comments:
Roots
Do you have an active root control program? El Yell No NA ❑NE
Describe AIA
Have cleaning and inspections ever been increased at this location because of roots? ❑Yes❑ No NA ❑NE T
Explain:
What corrective actions have been accomplished at the SSO location (and surrounding system if
associated with the SSO)?
What corrective actions are planned at the SSO location to reduce root intrusion?
Has the line been smoke tested or videoed within the past year? ❑Yes❑ No NA ❑ NE
If Yes, when?
Comments:
Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule in ny permit that
addresses 1/1?
[:]Yes] N,ZNAEv NE
CS-SSO Form October 9, 2003 Page 3

Explain if Yes:
What corrective actions have been taken to reduce or eliminate I & I related overflows at this spill location
within the last year?
Has there been any flow studies to determine 1/1 problems in the collection system at the SSO location? ❑Ye No ❑NA ❑NE
If Yes, when was the study completed and what actions did it recommend?
Has the line been smoke tested or videoed within the past year? ❑Ye No ❑NA ❑NE
If Yes, when and indicate what actions are necessary and the status of such actions:
Are there 1/1 related projects in your Capital Improvement Plan? Yes❑ No ❑NA Ll NE
If Yes, explain:
Have there been any grant or I an applications for 1/1 reduction projects? Q-YeL No ❑NA ❑NE
If Yes, explain:51m? � S�
Do you suspect any major sources of inflow or cross connections with storm sewers? ❑Ye o NA ❑NE
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream been inspected recently? Ye/ No ❑NA ❑NE
az
If Yes, explain:
What other corrective actions are planned to prevent future 1/1 related SSOs at this location?
Comments:
Pump Station Equipment Failure (Documentation of testing, records etc.,
shoul be provided upon request.)
What kind of notification/alarm systems are present?
Auto-dialer/telemetry (one-way communication)
CS-SSO Form October 9, 2003 Page 4

Audible
Visual
SCADA (two-way communication)
Emergency Contact Signage
Other
Des
Yes
❑Yes
Yes
❑Yes
Describe the equipment that failed? // -
What kind of situations trigger an alarm condition at this station (i.e. pump failure, power failure, high
water, etc.)?
74,
Were notification/aArm systems operable? Yes❑ No ❑NA NE
If no, explain:
If a pump failed, when was the last maintenance and/or inspection performed? ,,- _ ,clec�
.4 3 Z2 �1t�
What specifically was checked/maintained?
If a valve failed, when was it last exercised?
Were all pumps set to alternate? P Yes® No ❑NA ❑ NE
Did any pump show above normal run times prior to and during the SSO event? ❑YesB No ❑NA ONE
Were adequate spare parts on hand to fix the equipment (switch, fuse, valve, seal, etc.)? 21Yes1_1 No ❑ NA ❑ NE
Was a spare or portable pump immediately available? 21y'es❑ No ❑ NA ❑ NE
If a float problem, when were the floats last tested? How?
If an auto -dialer or SCADA, when was the system last tested? How?
Comments:
CS-SSO Form October 9, 2003 Page 5
/94

Power outage (Documentation of testing, records, etc., should be
provided of alternative power source upon request.)
What is your alternate power or pumping source?
e- IM41. •
Did it function properly? ❑Yes[] N01_/INA❑NE
Describe?
When was the alternate power or pumping source last tested under load?
If caused by a weather event, how much advance warning did you have and what actions were taken to
prepare for the event?
Comments:
Vandalism
Provide police report number:
Was the site secured?
❑Yes❑ No NA❑NE
If Yes, how?
Padlocked Control Panel
Have there been previous problems with vandalism at the SSO location? ❑Yes❑ No NA ❑ NE
If Yes, explain:
What security measures have been put in place to prevent similar occurrences in the future? ❑Yes❑ No NA ❑ NE
Comments:
Debris in line (Rocks, sticks, rags and other items not allowed in the
collection system, etc.)
What type of debris has been found in the line?
How could it have gotten there?
Are manholes in the area secure and intact? L J Ye N NA U NE
CS-SSO Form October 9, 2003 Page 6

When was the area last checked/cleaned?
Have cleaning and inspections ever been incfeased at this location due to previous problems with debris? ❑Yes❑ N , NA ❑NE
Explain:
Are appropriate educational materials being developed and distributed to prevent future similar ❑Yes❑ No NA ❑NE
occurrences?
Comments:
Other (Pictures and a police report should be available upon request.)
Describe:
Were adequate equipment and resources available to fix the problem? 11Yes❑ No NA ❑ NE
If Yes, explain:
If the problem could not be immediately repaired, what actions were taken to lessen the impact of the
SSO?
Comments:
For DWQ Use Only:
DWQ Requested an Additional Written Report: ❑Yes[] No❑NA❑NE
If Yes, What Additional Information is Needed:
Comments:
CS-SSO Form October 9, 2003 Page 7

As a representative for the responsible party, I certify that the information contained in this report is true and accurate
to the best of my knowledge.
Person submitting claim:
Ile
� A
= Date:
Signature:
Telephone Number: gc�� y8'o?&i 5
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five days of first
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of this form
is completed, if used).
CS-SSO Form October 9, 2003 Page 8

Contact: Robert Williams, Director- Regulatory Affairs
Blue Ridge Paper Products Inc.
Phone: (828) 646 —2033
Email: [e-mail]
For Immediate Release
NOTICE OF DISCHARGE OF UNTREATED WASTE
BLUE RIDGE
PAPER PRODUCTS INC.
Canton, NC -- September 9, 2004 -- On September 8, 2004 Haywood County and Western North
Carolina received floodwaters as a result of Hurricane Frances. North Carolina Governor Easley has
declared a state of disaster for all of North Carolina. The floods have caused the shutdown of Blue
Ridge Paper Products' wastewater treatment plant. Concomitant with this shut down manufacturing
operations were also curtailed and no industrial wastewater is being generated. The Blue Ridge
wastewater treatment plant also receives municipal waste from the Town of Canton. As a result of
this shut down untreated waste from the Town of Canton has been released to the Pigeon River.
As of September 9, 2004, the Blue Ridge wastewater treatment plant remains out of service and
untreated municipal waste is being discharge to the Pigeon River. The Town of Canton and Blue
Ridge Paper Products are working diligently to restore treatment of the Town's wastewater at the
earliest possible time. Canton Mill operations will not resume until all wastewater treatment plant
operations are restored.
Representatives of the Haywood County Health Department, the North Carolina Department of
Environment and Natural Resources and Haywood County Emergency Services have been notified
of flood damage to Canton and Blue Ridge wastewater treatment systems. These agencies are
monitoring actions to restore these services.

eiu 4-e,^ -e_A AS " (,(p S e- -L 1r
Form CS-SSO
Cokct)on System Se"Rary SowAr Overflow RepfkiC10 Form
lq%xdw PART i
This florin shall be submitted to the apprbpriM DWQ Regional Office within live Of the tlret tcrroa+ 001 of
the sarlimly tar W owerliow (650).
Permit Number: NCO025321 (WMC3# A wive, othnrwiigm use treatment plant HC:1V QN)
Faciily: Town or waynewoft vnvw trrcidant # 1
C*AW. TomorwaWnwdu wr4c
City: W-fl -ft county. H■raood
Sm" of AW (dmkck applicable) : t--t sanitary sewer PUMP t#atian
SPECIFIC kXmMon of the SW (be consistent In description from pest Pupa ts or dwarmentoWn - i.a_ PwW Station 0,
manhole at W%smli a iaram stem, eft.): p'"'� �rNrruewnewmdon sox.�w..rwm�ern.or■rsPrrs
la�tde (wnY
Incident Started Ot: 09-16- 2004 Tirne—!!:3t� incident End *.:+:R9-18-220 4 Time, 8:30 pm
cff yYyy) Mtlmmr AMPM (MM-dd ffm Mum A MPM
Eelbneted uohune of the 660: 881= Eatimeied Duration (Paundl to rte r" hrau A - --
0escribe how file Va ne W" dslW"nW.
Weather conrillo m during SW &M hood euw�t
Did SW reach surface wraters? O Yea0ro0 unknown VWWM resahi% xude m rhpb" (gations): 67,5W
Burface water nerve B W Crook ,
IXd Vw 5G0 resuk Ina Ash kW 11Yes R1No ❑ l nkwwn it Yes, what 1s the estimated number of fish kOtsd'l--....-
SKCIM cauae(s) of the 3t3D:
21 Severe Nahrral Condition ❑ or"" El ltaats
IJ MAW and IMilratiatr 0 PwW Sleaen Eiquip amd Faikm Poow mmW
C) Vandalism ❑ Dwfie in** ❑ 00W (Please explain In pert 11)
�Irmudtata 244mr verbal natiicadon raporied to ' ""Yn"
LT-,t ma 0 ammerxy Mprtrt. Ode (rr m4d-yyyy)- 09-17 2004 Tim®(hh:mm AM4*Q: 1p am
tf an SSO is ongoing, plem3 thi* Regional Office on a daily be0o until SSO can be stopped.
der (3.5.1�215.1C(b), Tito neeporteRrle i>f a 4rsrtrat9a d 1,t}O0 BaHatts cr mare d iwd wr�rralar' fa arttfaca
vraters shall kwus a ss 19MM vdthln a8�horxa of fast iarawl x* to all V t aad ek ckwft news media .pr0VWkV gar+eral
cavmage in 1ha caurdirq re arils occurgm Wjwn 15,000 geHane or more of uriftaa ed outfam
waters, a d is rx i e shall be published w" 10 deys and prW of putNiw o►► shM be provided io the Dhgak n witton 30 days.
Rtefer th the rtrfawrond aiaurle fnr htrthw detail.
The Director Oivision of Water GUM, May take erdioroemerd scam for SSN that arw to be nwxxw to Division Men It
1) the dts h"o was caused by severe rural conditlam and there ware no feaolble allornstives to the diacrutrf; ; or
2) the dlecharga was excepliond. urk0entiond, tamporpry and caused byfectrors beyond the masmable 0W*GI of me Penrittae
mWor owner, and the disc#mW maid nor tie" been pmverded by #is axwme Of re ENNW ie GW*Vl_
Part 11 moot be coarpkded to prudde aluetitica Lion dalm for either of the sbovm shotions. Thle inbmm*m wM be the Masts
for the delmminadon of any enfarcertterlt root.1herefore, it is Important to be as omolet# 00 poesible.
WHETHER OR NOT PART 1118 CWPLETED, A SIGNATURE IS REQUIRED AT THE END OF 1"S FORM,
C34SO Famr l bw 0 20M Page 4

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logo: 926-462-4M
L''r-r7
1� KOM HWM NC VENR Minna David Smith
A!�na DOW Sq*MW 16, 2004
M��a �i�lNa B
Ilw Qu�dilo� Repot �Otm +C�s
P t ®Mor M*w4* ► L7 Camwmid ©VII - a nuOy 0 Ml�wf
cow H KOM
If lm hum any queedom Siva me a cM
lDOM
I� SEP 21 2004
WATER QUALITY SECTION
;HFVILLE REGIONAL_OFFIC

E C v E
r9113,12004 15:57 828-733-1918 D M HARBOR POA PAGE 01
SEP 14 2004
�M
¢ Faaxl• cs'Ssc
; - � . • WATER QUALITY SECTION
'Coll igls> CE!flaw ReMrIing Form
PART I
This form shall be subm ttett to MO ap17rOpriate I3WO Regional Office within five days of the first knowledge of
the sanitary sewer overflow (5SQ).
Permit Number: WOO= BOOS# if active, atherMse use treatment plant Ncfwq#)
Facility: "1 Yi a
l ;Y^
406 Incident #
Owner: �61Region: —garb 41- _
Cityt:tAJ�QctRt� Costnty: v mil.
Source of SSO (check applicable) : Sanitary Sewer X Pump Station
SPECIFIC .locatlan of the SSC► (be'consistent in d • an Porn pest re r doounwritation - I.e. Pump Station B,
tut le at westall cps E r gq Street, ein.� : d S�wtGwhN.0
o s#+, ee imp,• 3(�'D �' I " re �.
Iagh de (degreeslmiriutf tsecond): - Lorngitude(degreestminutelsecond)- sz �33
Incident Started Dt: IIAI04 ±ime:_J'-#t1e AM lncldent Ent! Qt: g y ' f Time•. 9"dW
(mrn-dcr-yyyy) hh:rnm AM" (mrn-dd-yyyy} hh.,mm AANPM
Estimated volume of the SSO: gallons � `Es�kttated fJirratioR (l�ourrd to nearrast hour}: `/ '
Describe how the VolumO Was determined:
We$ther conditions during SSn --vent:ga
��`II"�+°� r"
Did $SO reach surface waters � _0 tUnknnvvn
Sui far water rwine: --
Did the SSO result in a frsh kill? C1 Yes Nrttia El Unknown
SPECIFIC r(s) of the SSG.-
Severe Natural Condition
Q inflow and InfiltmIlon
Vandalism
lmm;iiate 24-hour verbal notification reported to:
DWQ ED Emergency Mgrnt
VoluMe. vmrhing surface waters (gallons),- • T�.
If Yes, What Is the estimated number of fish kilted?
❑ Grease 0 Roots
© Pump Station Equipment Failure El Power outage
Q Debris in line Other (Plessa explain In Part 11)
Date JMM, dd-yyyyj- -rime (hh:mm ANUPM): �: ��• �x
If an 5$0 is ortgoing, please notify Regional Office on a daffy Basis until SSO can be stopped.
Per G.S. 143-215A C (b), the responsible p�r�y of a discharge of 1,000 gallons or more of untreated wastum4er to snrfacs
waters shall issue a press release wiiflin 4$-hours of first knowledge toad print and electronic news media providing general
coverage in the coun)y wh�d1schsrge occurred. When 15,000 gallons or more of untreated wastewater sneers surface
Marcos, a s{tt raHce shall be published within 10• dx_ ys and proof of pubiiimtlon shall be provided to the Division within aO days.
Refer to the referenced Statute for further detail.
The Director, Division of Waior Quality, may tatm enforcement action for SSCe that are mmauired to be rewrted to E)JvWan unless it
ie demonstrated them
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) tho diaotmae was exceptional, unintentional, tempormy and caused by factors beyond the reasonable control of -the Pmmittee
anftr owner, and the discharge could not have been praevergWil by the er miae of n3asonabie contrel.
Part 11 must he cornpleted to provide a jtatification ctalm for eit w of 110 above situations. This infQm wn wilt be the Dews
for the determination of any entercement action- Therafoie, It Is Important to be as obmpMe as possible.
WHETHER OR NOT PART II 1S C011r PI-ZMD, A SIGNATURE IS € SQUIRED AT THE END OF THIS FORM.
C-"SO Form acbober S,
Page ;1

15:5i
82B-733-191B
LAID HARBOR POA
PAGE 02
Fbrm CSSSO
CoileCtOn System Sanitary Sewer Overflow Reporting Foal)
_-. PART I I ..
FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN PART 1 OF THIS FORM
THE APPROPRIATE DOCUMENTATION AS REQUIRED On DESIRED
4LY THOSE SECTIONS PERTAINING TO TJE CAiJSE OF THE SSO AS Ci g7i-ir l HV PART i
In the check boxes below, NA ; Not Applicable and NE = Not Evaluated
A HARI)GOf Y OF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWQ REGIONAL OFFICe
UNLESS FT HAS BEEN SU13MIT-MO ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Severe Natural Condition (hurricane, tornado, eW.)
Describe il
the "severe nabj%W mndRion" in deta
11g�//1,wi-i 4ftA- r
How much advanca warning did )Muu have anti what actions were taken In preparrafl-il flhe event?
T. d of �G — L /" ►45 lotd4veC4 JV -twi llr i fzq —fMV'
Comments: fz'f --L1:4 �.
actions, past oveMow re_s�orts,_ eduaatlonat material and distribution elate, f f / F
etc. should tom. availWe upon request.) !
When was the last time this sper4c, fine (or wet well) was cleaned?
Do you have an enforceable grease ordinance ftlt requires new or retrofit of grease trapudbitemeptors? 0Ye.Q No 13NA ONE
Have there been recent inspections and/or ertftmement actions taken an nearby restaurmts or other
nonresidential grease C{7f1�r7 CIkOiS?
Explain.
Have there been other 5SOs or blockages in this•area that were also caused by grease? ❑Yes0 No ONA ONE
Men? '
If yet, desscnbe them-
Have cleaning and insoecfiorts ever been increased at this location? oyala W ❑NA LINE
Explain.
C,SSSQ Fenn- OcEobern. 200a
Page 2 -

9/13/2004 15:57 928-733-191B LAND HARBOR PDA PAGE 03
Have educational matorials about grease been divrIbuted in thu pasa
When?
and to whom?
Ely -so Na ©NADNE
Explain?
If ft DSO O=rred at a pump- station, when was the suet well and pumps test checked far grease
accurruJlation'?
Were the goats dean? 11Ye111 Na ❑NA MW
Comments:
Roots
I-
00 you have are active root contmi program? 1.JYeZ No ❑NA ❑NE
Describe
Have cleaning and inspections evor barn increased at this focal on he uzuse 'of rQgt$? ❑Yesd No EINA ❑ mE
Explain:
What correrdive actions have been accnmpiishad at ibe 880 localon (and surrounding sysaern if
associated with the $$0)7
What coryarklve actlons are planned at the SSO iacatlon to reduce root Intrusion?
Has thR line been smal a tested or videced within the past year? 0YL-,.0 Na LIMA © WF7
Wyes, when?
Cownents:
Inflow and Infiltraffe)n
Am.you under an SOC (Specie) C74i$er by Consent) or do you have a schedule in any permit that 0Yes0 No I- NA LINE;
addresses Ill?
CS-SSQ Form October 9, 2443 Page 3

113i12004 15:57 B2B-733-1418 LAND HARBOR POA PAGE 04
Exphdn ifYes:
VM21 cor+ecffve actions have been taken to reduce or eliminate t & I related 0=1110M at thi$ spill lccaWn
within the last yew[? r
Has there been any Ww studies to tiefenmine Ui problems in the collection system at the S$p locatian7 OY-0 NO DNA LINE
If Yes, when was the study completed and what actions did it recammend?
Has the line been Smaka tested o€ videced within the past year! E]YeO No ©NA FINE -
If Yes, when and indicate what actions are necessary and the sl atus of such actions:
Are there U1 related projects In your Capital tmproventent Plan? 0Yr;10 No UNA ONV
If Yes, explain:
Have there been ar)y grant or loan appliraftns for Ill reducifan projects? OYO.0 No F-INA ❑ICE
It Yes, explain:
Do you suspect any moor sours of inflow or cross conrieiAons with storm sewers? ©Yes0 Na [INA ©NE
If Yes. explain:
Have all flues contacting surface waters in the 550 location and upstream been inspected recently? E3y.0 Na DUA DNE
If Yes, explain:
What o1hercorredfive actions am prannetd to prevent future Its related SSOs at this location?
C�rtrnents:.
Pulrl� Station i=gtiipmerrt Failure (Documentation of testingx_remrds_ etc_,
shout be provided. upon request.)
What kind of nbtificatiordWwm sysiens are present'?
Auto-dialerflulemetry (on& -may communication) Dyes
CS-SSO Farm October 9, 2003 Pape 4

104 15:57 828-733-1918
Aadi$JQ '
Visual
SCADA (two-way communication)
ZAmergency Contact Signage
Otfhbr
LAhM HARBOR POA
PAGE 05
DYe a
Dyes
DYes
DYes
Describe the equipment thatfaiW?
What kind of situations trigger an alarm condition at this sjmOon (i.e. pump failure, powee Miure, high
wftte r etc.)? t-�t
Were Wtl�lblationtalarm systems vpem? L.-IYesD No ©NAA DNE
If no, Main:
If a pump killed, when was the last maartertance and/or inspeciion pertormed7 -
What specifically Was checkedimaintained?
If a valve failed, when was it last exercised? +� �7
Were aft pumps Set to altern2te?' f� - Y� M DNA ONE
Did any pump show above nonrmi run times prior tv and during the SSO event? DYc s0 No DN,4'D14E
Were adequate spare parts on hand to fix the equipmeot (switch. hise. valve, seal, etc_)? DYesD No EINAADNE
t
Was a spare or parlahle pump immediately available? DYesD Ne Dt+IA ONE
If a goat problem, when were the floats last tested? How?
It an auto-d!1er or SCADA. when was the system last testaV How?
CSSSC? Form ' 0cober9; 2003
M
Page 5

13/2004 15:57 828-733-1918 LAND HARBOR PDA PAGE 06
Of
Provided of aitemaWe power source upc
What is your alernste-power or pumping source?
be
Did It ffunadon propedY7 'Ely-O No DNA ONE
Descfiire? .
When was the altema7le power or pumping source Iasi tested under load?
If caused by a weather event, haw much advance warning did you hwp-- and what actions wera Taken to
prepam •for the event?
Commenter
Vandalism
Provide police report• number.
Was the site secured?
0Ye10 No ©NA QNI=
It Yes, how?
Have there been previous -problems with vandafism at the SSO iocation? ©Ye,F-1 No ©NA 13NE
If Yes, explain:
What smrny measures have been put In place to prevent similar omurranms in the future? ©Y JJ N, CINA FINK
Comments:
Debris in sine (Roder, sticks, rays and other items not allowed in the
collection s+ysM, aw)
What "of debris has been fpund in aw Nine? 1Y14
How CQUId it have gotten thttre?
Are rnanf"as in the area *ackn a and kA&07 ©Y�.o No 13FM OTqe.
CS-SS0 Form Omber 9, 21703 Pao 8

09/13,12004 15:57 B28-733-1918 LAND HARBOR PDA PAGE 07
When was fhe area fast oheckedldeaned?
Have df�anfng and insimCdons ever been increased at this location due to previous problen7s wiii7 debris? OYeZ Ada EINA ©NE
Expiain:
Are appropriate edurattonaf materials buing dinveloped and dfsM-buted tn•35revent futum similar OY Z N.0NA ©NE
accurrenres'� .
Comments:
'Other (Pictures and a p21ico_teport should be available upon request),
Describe:
Wert adequaib e[ uipment and resources available to lix the problem? QYe.0 Mtn UNA ONE
If Yes, explain:
If the problem could not be immediately repafrect, what actions were taken to lessen the fiapact of the
� t
Comments:
For DWQ Use Only-,.
DWQ Requested an Additional Wrftien Rep=
IfYas, MiatAddWonaf Information is Needed:
Comments
13YIJ:3 No [INA ONE
CS-SSOFQ= october9.2003 Page 7'

09/13/2004 15:57 B28-733-1918 LAND HARBOR PEA PAGE 08
As a represantative for the jespansibfe party, 1_ certify fhsT the. Information eontained In this repork is lruc� and accurate
to the beM of my knowledge.
Person submitting ciaim; Wx- d ,r1 t7afe
113
Signature: _
Title,
Telephone Number --
Any addManaf information desired to be submitted -should be. sent to the appropriate Division Ragionof Office within five days offimt
k"Duvledge of the 380 with• rt A.-=ce to the incident number (tire (ndden.t number is only generated when electronic entry of this form
is completed, if ustd). /
CS -WO Form Cci berg, 2003 page 9
i

61w .+...w7 .w ry ci cvcnvvv wvv�.
Permit Number: (WQCS# if active, otherwise use treatment plant NC/WQ#)
Facility: T D - (q
Owner:
a Incident #
rr `` Region:
City: V' I County::
Source of SSO (check applicable) : Sanitary Sewer Pump Station
SPECIFIC location of the SSO (be consistent iip description from past repo s or doc " ntati n - i.e. Pum tation 6,
Manhole at Westall & Bragg Street, etc.) : Ca� .t�'� (� t f;�5 v�V, a
Latitude (degrees/minute/second): \ g Longitude(degrees/minute/second)•
Incident Started Dt�' ® Time. °0o Incident End Dt: 'OQV Time-
hh:mm ®� C) �1,
(mm-dd-yyyy) AWPM (mm-dd-yyyy) hh:mm AM/PM .
( 000 ' cat
Estimated volume of the SSO: 55 �` Olons J stimated Duration (Round to nearPct hnijr)• iq )r)5
Describe how the volume was determir
Weather conditions during SSO event:
Did SSO reach surfac aters? ® yes U No U Unknown
Surface water name:
Did the SSO result.in a fish kill? El Yes ® No Unknown
SPECIFICpause(s) of the SSO:
Yal Severe Natural Condition
Inflow and Infiltration -
Vandalism
Immediate 24-hour verbal notification reported to:
® DWQ 0 Emergency Mgmt.
Volume reaching surface waters (gallons):
If Yes, .what is the estimated. number of fish killed?
El Grease E
El Pump Station Equipment Failure G
Debris in line
Roots
Power outage
Other (Please
Part II)
Date (mm-dd-yyyy): Q� _ d•.O (t Time (hh:mm AM/PM): qj ; _M)
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped..
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer_ to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that.
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to'the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of seasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003 Page 1

Form CS -SSA
Collection System Sanitary Sewer Overflow Reporting Form
ANSWER THE FOLLOWINGQUESTIONSFOR EACH RELATED CAUSE CHECKED IN PART I OF THIS FORM
AND INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN PART I
In the check boxes below, NA = Not Applicable and NE = Not Evaluated
A HARDCOPY OF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWQ REGIONAL.OFF.ICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH_ THE ONLINE REPORTING SYSTEM
Severe Natural Condition (hurricane, tornado, etc.
Describe the "severe natural condition" in detail. _
How much advance warning did you have and what actions were taken in preparation for the event?pC-S
Comments
Grease (Documentation such as cleaning, inspections, enforcement
actions, past overflow reports; educational material and distribution date,
etc. should be available upon request.)
When was the last time this specific line (or wet well) was cleaned?
Do you have an enforceable grease ordinance that requires new or retrofit of grease traps/interceptors?
Have there been recent inspections and/or enforcement actions taken on nearby restaurants or other
nonresidential grease contributors?
Explain.
❑Yes❑ No❑NA❑NE
❑Yes❑ No❑NA❑NE
Have there been other SSOs or blockages in this area that were also caused by grease? ❑Yes❑ No ❑ NA ❑ NE
When?
If yes, describe them:
Have cleaning and inspections ever been increased at this location? ❑Yes❑ No ❑ NA El NE
Explain
CS-SSO-Form October 9, 2003 Page 2

als about grease been distributed in the past?
and to whom?
Explain?
If the SSO occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation?
Were the floats clean?
Comments:
❑Yes❑ No❑NA❑NE
❑Yes❑ No❑NA❑NE
Roots
Do you have an active root control program? ❑YesO No ❑ NA ❑ NE
Describe
Have cleaning and inspections ever been increased at this location because of roots? ❑Yes❑ No ❑ NA ❑ NE .
Explain:
What corrective actions have been accomplished at the SSO location (and surrounding system if
associated with the SSO)?
What corrective actions are planned at the SSO location to' reduce root intrusion?
Has the line been smoke tested or videoed within the past year? ❑Yes❑- No ❑ NA ❑ NE
If Yes, when?
Comments:
Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule in any permit that. ❑Yes❑ No ❑ NA ❑ NE
addresses 1/1?
CS-SSO Form October-9, 2003 Page 3

Explain if Yes:
What corrective actions have been taken to reduce or eliminate I & I related overflows at this spill location
within the last year?
Has there been any flow studies to determine 1/1 problems in the collection system at the SSO location? ❑Yes❑ No ❑NA ❑NE
If Yes, when was the study completed and what actions did it recommend?
Has the line been smoke tested or videoed within the past year? ❑Yes❑ No ❑ NA ❑ NE
If Yes, when and indicate what actions are necessary. and the status of such actions:
Are there 1/1 related projects in your Capital Improvement Plan? ❑Yes❑ No 0 NA ❑ NE,
If Yes, explain:
Have there been any grant or loan applications for 1/1 reduction projects? ❑Yes❑ No ❑ NA ❑ NE
If Yes, explain:
Do you suspect any major sources of inflow or cross connections with storm sewers? El Yes[] No ❑ NA ❑ NE
If Yes, explain: .
Have all lines contacting surface waters in the. SSO location and upstream been inspected recently? ❑Yes❑ No El NA 1-1 NE
If Yes, explain:
What other corrective actions are planned to prevent future 1/1 related SSOs at this location?
Comments:
Pump Station Equipment Failure (Documentation of testing, records etc.,
shoul be provided upon request.)
What kind of notification/alarm systems are present? .
Auto-dialer/telemetry (one-way communication) ❑Yes
CS-SSO Form - October 9, 2003 Page 4

a
SCADA (two-way communication)
Emergency Contact Signage
Other
Describe the equipment that failed?
What kind of situations trigger an alarm condition at this station (i.e. pump failure, power failure, high
water, etc.)?.
Were notification/alarm systems operable? ❑Yes❑ No ❑NA❑NE
If no, explain:
If a pump failed, when was the last maintenance and/or inspection performed?
What specifically was checked/maintained?
If a valve failed, when was it last exercised?,.
Were all pumps set to alternate? ❑ Yes❑ No ❑ NA ❑ NE
Did any pump show above normal run times prior to and during the SSO event? ❑Yes❑ No ❑ NA ❑ NE
Were adequate spare parts on hand to fixthe equipment (switch, fuse, valve, seal, etc.)? ❑Yes❑ No ❑NA❑NE
Was a spare or portable pump immediately available? ❑Yes❑ No ❑ NA ❑ NE
If a float problem, when were the floats last tested? How?
If an auto -dialer or SCADA, when was the system last tested? How?
Comments:
CS-SSO Form October_g, 2003 Page 5

Power outage (Documentation of testing, records, etc., should be
provided of alternative power source upon request.)
What -is your alternate power or pumping source?
Did it function properly? ❑Yes❑ No❑NA❑NE
Describe?
When was the alternate power or pumping source last tested under load?
If caused by a weather event, how much advance warning did you have and what actions were taken to
prepare for the event?
Comments:
Vandalism
Provide police report number:
Was the site secured? ❑Yes❑ No ❑ NA 1-1NE
If Yes, how?
Have there been previous problems with vandalism at the SSO location? El Yell No El NA ❑NE
If Yes, explain:
What security measures have been.put in place to prevent similar occurrences in the future? ❑Yes❑ No ❑ NA ❑ NE
Comments:
Debris in line (Rocks, sticks, rags and other items not allowed in the
collection system, etc.)
What type of debris has been found in the line?
How could it have gotten there?
Are manholes in the area secure and intact? ❑Yes[] No ❑ NA ❑ NE
CS=SSO Form . October 9, 2003 Page 6

s the area last checked/cleaned?
Have cleaning and inspections ever been increased at this location due to previous problems with debris? ❑Yes❑ No ❑ NA ❑ NE
Explain:
Are appropriate educational materials being developed and distributed to prevent future similar ❑Yes❑ No ❑ NA ❑ NE
occurrences?
Comments:
Other (Pictures `and a police report should be available upon request.)
Describe:
Were adequate equipment and resources available to fix the problem? ❑Yes❑ No ❑ NA ❑ NE
If Yes, explain:
If the problem could not* be immediately repaired, what actions were taken to lessen the impact of the
SSO?
Comments:
For DWQ Use Only:
DWQ Requested an Additional Written Report:
If Yes, What Additional Information is Needed:
Comments:
El Yes[] No❑NA❑NE
CS-SSO Form October.9, 2003 Page 7

As.a representative for the responsible party, I certify that the information contained in thisreport is true and accurat
to the best of my knowledge.
Person submitting claim Date: 1" 04
Signature; oea Title:
cam_
..Telephone Number: wo
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five days of first
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of this form
is completed, if used).
CS-SSO Form October 9, 2003 Page 8

fJ -
Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
PART I
This form shall be submitted to the appropriate DWQ Regional Office within five daysof the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number: NC 0000272 (WQCS# if active, otherwise use treatment plant NC/WQ#)
Blue Ridge Paper Products, Inc. - Wastewater Treatment Plant
Facility: Incident #
Region:
Owner:
Blue Ridge Paper Products, Inc. Asheville
City: Mill also treats wastewater for Town of Canton, NC County: Haywood Co.
Source of SSO (check applicable) : 21 Sanitary Sewer 0 Pump Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation - i.e. Pump Station 6,
Manhole at Westall & Bragg Street, etc.) : Multple overflows to Pigeon River in Canton, NC during and after flood until flood damage could be repaired.
Latitude(degrees/minute/second): 35/32/06 Long itude(degrees/minute/second): 82/50/34
Incident Started Dt: 09-08-2004 Time: 3:00 am Incident End Dr09-11-2004 Time: 12:50 pm
(mm-dd-yyyy) hh:mm AM/PM (mm-dd-yyyy) hh:mm AM/PM
unknown > 15,000 -�g-
Estimated volume of the SSO: gallons Estimated Duration (Round to nearest hour 07—
Describe how the volume was determined: flood conditions, overflow mixed with flood waters, total volume unknown
Weather conditions during SSO event: Hurricane Frances, record flood on Pigeon River in Canton, NC
Did SSO reach surface waters? 0 Yes❑No❑ Unknown Volume reaching surface waters (gallons): unknown
Surface water name: Pigeon River
Did the SSO result in a fish kill? ❑ Yes E No ❑ Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
Severe Natural Condition ❑ Grease ❑ Roots
❑ Inflow and Infiltration ❑ Pump Station Equipment Failure ❑ Power outage
Vandalism 1:1Debris in line ❑ Other (Please explain in Part II)
Immediate 24-hour verbal notification reported to: DENR 1-800 number at 07:45 on 9/8, follow-up with Keith Haynes ARO
0 DWQ L-!�J Emergency Mgmt. Date (mm-dd-yyyy): 09-08-2004 Time (hh:mm AM/PM): 7:45 am
IfilIf an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where a the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
Is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003
Page 1

Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
PART I I
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN PART I OF THIS FORM
AND INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN PART I
In the check boxes below, NA = Not Applicable and NE = Not Evaluated
A HARDCOPY OF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWQ REGIONAL OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Severe Natural Condition (hurricane, tornado, etc.)
Describe the "severe natural condition" in detail.
Passage of Hurricane Frances resulted in record flood, overtopped flood dikes and flooded WTP.
How much advance warning did you have and what actions were taken in preparation for the event?
Activated flood plan on 9/7 and took all reasonable precautions to prevent flood of WTP
Comments:
Blue Ridge Paper WTP also treats sewage from Town of Canton. Mill shutdown, sewage from town overflowed.
Grease (Documentation such as cleaning, inspections, enforcement
actions, past overflow reports, educational material and distribution date,
etc. should be available upon request.)
When was the last time this specific line (or wet well) was cleaned?
Do you have an enforceable grease ordinance that requires new or retrofit of grease traps/interceptors?
Have there been recent inspections and/or enforcement actions taken on nearby restaurants or other
nonresidential grease contributors?
Explain.
Have there been other SSOs or blockages in this area that were also caused by grease?
When?
If yes, describe them:
Have cleaning and inspections ever been increased at this location?
Explain.
CS-SSO Form October 9, 2003
Not applicable
[]Yes[:] NoUNA❑NE
[:]Yes[:] No DNA❑NE
No UNAUNE
No
Page 2

it grease been distributed in the past?
and to whom?
Explain?
If the SSO occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation?
Were the floats clean?
Comments:
Roots
Do you have an active root control program?
❑Yes❑ NA' ,ONE
❑Yes❑ No NA❑NE
❑Yes❑ NoDNA❑NE
Describe
Have cleaning and inspections ever been increased at this location because of roots? ❑Yes❑ No NA ❑NE
Explain:
What corrective actions have been accomplished at the SSO location (and surrounding system if
associated with the SSO)?
What corrective actions are planned at the SSO location to reduce root intrusion?
Has the line been smoke tested or videoed within the past year?
If Yes, when?
Comments:
Yes❑ NoONA❑NE
Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule in any permit that ❑Yes❑ No NA ❑NE
addresses I/I?
CS-SSO Form October 9, 2003
Page 3

.. en taken to reduce or eliminate I & I related overflows at this spill location
within the last year?
Has there been any flow studies to determine 1/1 problems in the collection system at the SSO location? ❑Yes❑ No NA -NE
If Yes, when was the study completed and what actions did it recommend?
Has the line been smoke tested or videoed within the past year? ❑Yes❑ No NA ❑NE
If Yes, when and indicate what actions are necessary and the status of such actions:
Are there 1/1 related projects in your Capital Improvement Plan? Yes❑ No[ANACINE
If Yes, explain:
Have there been any grant or loan applications for 1/1 reduction projects? ❑Yes❑ No EINA❑NE
If Yes, explain:
Do you suspect any major sources of inflow or cross connections with storm sewers? []Yes[-_] No EINA❑NE
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream been inspected recently? []Yes[No NA ❑NE
If Yes, explain:
What other corrective actions are planned to prevent future 1/1 related SSOs at this location?
Comments:
Pump Station Equipment Failure (Documentation of testing, records etc.,
shoul be provided upon request.)
What kind of notification/alarm systems are present?
Auto-dialer/telemetry (one-way communication) DYes
CS-SSO Form October 9, 2003 Page 4

V MUCH
SCADA (two-way communication)
Emergency Contact Signage
Other
aes
❑Yes
❑Yes
❑Yes
[]Yes
Describe the equipment that failed? _
Flood waters submerged WTP and sewage pump stations, power was cut before flooding
What kind of situations trigger an alarm condition at this station (i.e. pump failure, power failure, high
water, etc.)?
high level
Were notification/alarm systems operable? []Yes[:] No BNA UNE
If no, explain:
If a pump failed, when was the last maintenance and/or inspection performed?
What specifically was checked/maintained?
If a valve failed, when was it last exercised?
Were all pumps set to alternate?
Did any pump show above normal run times prior to and during the SSO event?
Were adequate spare parts on hand to fix the equipment (switch, fuse, valve, seal, etc.)?
Was a spare or portable pump immediately available?
If a float problem, when were the floats last tested? How?
If an auto -dialer or SCADA, when was the system last tested? How?
Comments:
CS-SSO Form October 9, 2003
[]Yes[] No uNA ❑NE
❑Yes❑ No N FINE❑Yes❑ No7NAEOINE
NE
❑Yes❑ No
Page 5

etc., should be
PP_ What is your alternate power or pumping source?
Did it function properly? ❑Yes❑ No UA ❑NE
Describe?
When was the alternate power or pumping source last tested under load?
If caused by a weather event, how much advance warning did you have and what actions were taken to
prepare for the event? Activated flood plan on 9/7 and took all reasonable precautions to prevent flood of WTP
Comments:
Vandalism
Provide police report number:
Was the site secured?
If Voc hnni7
Padlocked Control Panel
Have there been previous problems with vandalism at the SSO location?
If Yes, explain:
❑Yes❑ NoLJNA❑NE
No UNA UNE
What security measures have been put in place to prevent similar occurrences in the future? ❑Yes❑ No NA ❑ NE
Comments:
Debris in line (Rocks, sticks, rags and other items not allowed in the
collection system, etc.)
What type of debris has been found in the line?
How could it have gotten there?
Are manholes in the area secure and intact? Ye No ENA UNE
CS-SSO Form October 9, 2003 Page 6

i/cleaned?
nave utianury anu rrrspectruns ever been increased at this location due to previous problems with debris? ❑Yes❑ No NA ❑NE
Explain:
Are appropriate educational materials being developed and distributed to prevent future similar []Yes[ No NA ❑NE
occurrences?
Comments:
Other (Pictures and a police report should be available upon request.
Describe:
Were adequate equipment and resources available to fix the problem? []Yes[-] No DNA ❑ NE
If Yes, explain:
If the problem could not be immediately repaired, what actions were taken to lessen the impact of the
SSO?
Comments:
For DWQ Use Only:
DWQ Requested an Additional Written Report:
If Yes, What Additional Information is Needed:
Comments:
[]Yes❑ No NA ONE
SSOs were result of major flood event that damaged wastewater treatment plant owned by Blue
Ridge Paper Products and also damaged sewage pump stations owned by Town of Canton. See
letter from Blue Ridge Paper Products dated 14 Sep 2004.
CS-SSO Form October 9, 2003
Page 7

Person submitting claim: Bob Shanahan Date: 14 Sep 2004
Signature: % Title: VP and Mill Manager
Telephone Number: 828-646-2840
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five days of first
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of this form
is completed, if used).
Reference letter from Blue Ridge Paper Products dated 14
September 2004.
CS-SSO Form October 9, 2003
Page 8

• Regulatory Affairs
Email: [e-mail]
BLUE RIDGE
- PAPER P-ROD-UGTS INC.
For Immediate Release
NOTICE OF DISCHARGE OF UNTREATED WASTE
Canton, NC -- September 9, 2004 -- On September 8, 2004 Haywood County and Western North
Carolina received floodwaters as a result of Hurricane Frances. North Carolina Governor Easley has
declared a state of disaster for all of North Carolina. The floods have caused the shutdown of Blue
Ridge Paper Products' wastewater treatment plant. Concomitant with this shut down manufacturing
operations were also curtailed and no industrial wastewater is being generated. The Blue Ridge
wastewater treatment plant also receives municipal waste from the Town of Canton. As a result of
this shut down untreated waste from the Town of Canton has been released to the Pigeon River.
As of September 9, 2004, the Blue Ridge wastewater treatment plant remains out of service and
untreated municipal waste is being discharge to the Pigeon River. The Town of Canton and Blue
Ridge Paper Products are working diligently to restore treatment of the Town's wastewater at the
earliest possible time. Canton Mill operations will not resume until all wastewater treatment plant
operations are restored.
Representatives of the Haywood County Health Department, the North Carolina Department of
Environment and Natural Resources and Haywood County Emergency Services have been notified
of flood damage to Canton and Blue Ridge wastewater treatment systems. These agencies are
monitoring actions to restore these services.

Form . CS-:SSO
Overflow Reporting Form.
This form shall be submitted to the appropriate DW eglona ice v tilin fiv e-aaw of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number: �GOD�� 5 (WQCS# if active, otherwise use treatment plant NC/WQ#)
Facility:
LLm M' &Jr W Incident #
Owner:..txf'LLAv%d FDA'ItG Region:
A
S 1
City:
County: Ava-V
Source of SSO (check applicable) : Sanitary Sewer Pump Station
SPECIFIC location of the SSO (be consistent in d ((scnPtion from past repoj�f r documentation - i.e. Pump Station 6,
Manh le at Westall & Bragg Street, etc.) :.MumolL Iv'"Y'17M� RJp0'*,'Itd'H -X4 a, M*JOWS. SdWCrp1*.44 }. +Wp $ M1.11aS
if +v scoiGr PIAwf D s u
Latitude (degrees/minute/second): 3(� 6 Z 11 Longitude(degrees/minute/second)• /lI S3 '33 *#
Incident Started Dt: 9 B 04 Time J.'Ob '404 ' Incident End Dt: 9 �6 Time- 91140 TAl
(mm-dd-yyyy) hh;mm AM/PM (mm-dd-yyyy) .hh:mm AM/PM
Estimated volume of the SSO: �'� gallons Estimated Duration (Round to, nearest hour): 6
Describe how the volume was determined: tXPbri "& 15'A�
.Weather conditions during SSO, event:.
Did SSO reach surface waters? Yes ON D Unknown
Surface water name:
Did the SSO_result in a fish kill? Yes u No Unknown
SPECIFIC cause(s) of the SSO:
Volume reaching surface waters (gallons): C jn -
If Yes, what is the estimated number of fish killed?
5?'Severe;Natural Condition-
Grease
Roots
El Inflow and Infiltration
Pump Station Equipment Failure
0 Power outage
El.-
. Vandalism , .
0
Debris in line
0 Other (Please explain in Part ll)
Immm late 24-hour verbal notification reported to:
'_--r DWQ Emergency Mgmt.
Date (mm-dd-yyyy): 9 AjTime (hh;mm AM/PM):
If an. SSO is ongoing, please notify Regional Office on a daily basis until SSO can be, stopped.
Per G.S. 143-215.1 C(b), the responsible party -of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2)1 the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part it must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement. action. Therefore, it is important to be as complete as possible..
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003 Page 1

WAS
Collection 'System Sanitary Sewer C
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN PART I OF THIS FORM
AND INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN PART l
In the check boxes below, NA = Not Applicable and NE = Not Evaluated
A HARDCOPY OF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWQ REGIONAL OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Severe Natural Condition (hurricane, tomado, etc.)
Describe the "severe natural condition" in detail.
I/uNi'i cwk.a -4:6�5 -- `o?aZ -/: I�A,•1vf'7✓`G ` pJ; , y. � � �l�?t�'' �t74G�'e0 ,
How much advance warning did you have and what actions were taken in preparation• for the event?
-41d-/AdV-#1S - /A& /6�11/ -43 /ww,e'd b 1 4&41V AV/,z, -sqw.nol-e,4M54 7$
Comments: /0- - n �� e&er ..4-G(.
(M1C, �7,,,(T Q/ 7'-G0i7�a6Fr�O1 'r/VlTi0 V-Vo•kw�r 46&^'lr
Grease (Documentation such as cleaning, inspections, enforcement
actions, past overflow reports, educational material and distribution date,
etc. should be. available upon request.)
When was the last time this specific line (or wet well) was cleaned?
Do you have.,an enforceable grease ordinance that requires new or retrofit of grease traps/interceptors?
Have there been recent inspections and/or enforcement actions taken on nearby restaurants or other
nonresidential grease contributors?
Explain.
Have there been other SSOs or blockages in this, area that were also caused by grease?
When?
If yes, describe them:
Have cleaning and inspections ever been increased at this location?
Explain.
❑ Yes❑ No ❑ NA ❑ NE
❑Yes❑ No DNA ❑NE
[:]Yes[:] No ❑ NA ❑ NE
El Yes[] No ❑NA ❑NE
CS-SSO Form October 9, 2003 Page 2

Explain?
If the SSO occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation?
Were the floats clean?
Comments: .
E]YesD No ONA ONE
Roots A
Do you have an active root control program? ❑YesO No ❑NA ONE
Describe;
Have cleaning and inspections ever been increasedat this 1oo66'tion because of roots? 0YesO No ONA ONE
Explain:
What corrective actions have been. accomplished at the SSO location (and surrounding system if ,
associated with the SSO)?
What corrective actions are planned at the SSO location to reduce root intrusion?
Has the line been smoke tested or videoed within the past year? ❑YesO No DNA ❑ NE
If Yes, when?
Comments:
Inflow and Infiltration A1f j
Are -you under an SOC (Special Order by Consent) or do you have a schedule in any permit.that E]YesD No ONA NE
addresses 1/1?
CS-SSO Form October 9, 2003
Page 3

Explain if Yes:
What corrective actions have been taken to reduce or eliminate I & I related overflows at this spill location
within the last year?
Has there been any flow studies to determine 1/1 problems in the collection system at the -SSO location? El Yes[] No El NA ❑NE
If Yes, when was the study completed and. what actions did it recommend?
Has the line been smoke tested or videoed within the past year? ❑Yes❑ No ❑ NA ❑ NE
If Yes, when and indicate what actions are necessary and the status of such actions:
Are there III related projects in your Capital Improvement Plan? ❑Yes❑ No ❑NA El NE
If Yes, explain:
Have there been any grant or loan applications for 1/1 reduction projects? ❑Yes❑ No ❑NA El NE
If Yes; explain: -
Do you suspect any major sources of inflow or cross connections with storm sewers? ❑.Yes❑ No ❑NA ❑NE
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream been inspected recently? ❑Yes❑ No ❑NA ❑NE
If Yes, explain:
What other corrective actions are planned to prevent future 1/1 related SSOs at this location?
Comments:
Pump Station Equipment Failure (Documentation of testing, records etc.,
shoul be provided. upon request.) AIIA
What kind of notification/alarm systems are present?
Auto-dialer/telemetry (one-way communication) ❑Yes
CS-SSO Form October 9, 2003 Page 4

Describe the equipment, that failed?
., What kind of situations trigger an alarm condition at this station (i.e. pump failure, power failure, high
water, etc.)?
Were notification/alarm systems operable?
DYesO No DNA ❑NE
If no,' explain:
If a pump failed,.when was the last. maintenance and/or inspection -performed?
_What'specifically was checked/maintained? '
If a valve failed; when was it last exercised?
Were all pumps set to alternate?'
❑Yes0 No ❑ NA O NE
Did any pump show above normal" run times prior to and during the SSO event?
❑YesEl No ❑ NA 0 NE
Were adequate spare parts on hand to fix the equipment (switch, fuse, valve, seal, etc.)?
DYesD No ❑ NA ❑ NE
Was a spare or portable pump immediately available?
Yes No ❑NA ONE .
If afloat. problem, when were the floats last tested? How?
If an auto -dialer or SCADA;when was thesystem last tested? How?
Comments:
-'CS-SSO Form October9, 2003.
Page .5 . .

Power outage (Documentation of testing, records, etc., should be
provided of alternative power source upon request.)
What is your alternate power or pumping source?
Did it function properly? LJYesLI No LJNA LJNE
Describe?
When was the alternate power or pumping source last tested under load?
If caused by a weather event, how much advance warning did you have and what actions were taken to
prepare for the event?
Comments:
Vandalism
Provide police report number:
A110-
Was the site secured? ❑YesEl No ❑NA El NE
If Yes, how?
Have there been previous problems with vandalism at the SSO location? ❑Yes❑ No DNA ❑NE
If Yes, explain:
What security measures have been put in place to prevent similar occurrences in the future? 11Yes❑ No ❑ NA ❑ NE
Comments:
Debris in line (Rocks, sticks,` rags and other items not allowed in the
collection system, etc.)
What type of debris has been found in the line?
How could it have gotten there?
Are manholes in the area secure and intact? ❑Yes❑ No ❑NA ❑NE .
CS-SSO Form October 9, 2003 Page 6

area last checked/cleaned?
e cleaning and inspections ever been increased at this location due to previous problems with debris?' ❑Yes❑ No ❑NA ONE
Explain:
Are appropriate educational -materials being developed and distributed to prevent future similar'.. ❑Yes❑ No El NA ❑NE
occurrences?
Comments:
Other (Pictures and a police report should be available upon request.)
Describe:_
Were adequate equipment and resources available to fix the problem? ❑Yes❑ No El NA ONE
If Yes, explain:
If the problem could not be immediately repaired, what actions were taken to lessen the impact of the _
SSO? `
:,Comments:
For DWQ Use Only:
DWQ Requested an Additional Written Report: ❑Yes❑ No ❑NA ONE
If Yes, What Additional Information, is Needed:.
Comments:
CS-SSO Form October 9, 2003' Page 7'

As a - representative for the responsible paI certify that the information contained in this reporte andto the best of my knowledge.
Person submitting claim:yA�Date:L��
It
Signature: AV Qljp��
Title: V
Telephone Number:
Any additional information desired to be submitted -should be sent to the appropriate Division Regional Office within five days of first
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of this form
is completed, if used).
Page 8

Notice of Discharge of Untreated Sewage
Land Harbor Property Owners Association had a discharge of sewage from
er treatment plant, pump station and sewer main located at 180 Overlook
Road of approximately 20,000 gallons. The discharge was first discovered on September
8, 2004 at 3:00 a.m. and lasted for approximately 61 hours. The untreated wastewater
entered the Linville River of the Catawba River basin. The treatment plant, pump station,
and sewer main were repaired and back in operation by 4:00 p.m. on September 10, 2004.
This notice was required by North Carolina General Statutes Article 21 Chapter
143.215.C.

LINVILLE LAND HARBOR
PROPERTY OWNERS ASSOCIATION
Post Office Box 160
Linville, North Carolina 28646
828-733-8300
September 13, 2004
Keith Haynes
N.C. Division of Water Quality
2090 U.S. Hwy. 70
Swannonoa, N.C. 28778
Dear Mr. Haynes,
Attached you will find the original Collection System Sanitary Sewer Overflow
Reporting Form which was faxed to your office on September 13, 2004. Also included is
a copy of the public notice that was sent to the Avery Journal for publication. As soon as
I received the certified verification from the newspaper, I will send it to you as well. In
light of the circumstances, I was extremely proud of the way our staff responded and
eliminated the problem so quickly. If you have any questions, please do not hesitate to
contact me at [phone].
Sic ly,
�K
/V.
KMin.Itl
McCracken
General Manager
knm
�P , 6 2004 D
WATER QUALITY SECTION

!pm From -BLUE RIDGE PAPER
p E C E 1
828646689
S EP 1 4 2004
HEVILLE REGIONAL OFF
T- f7/019 F-384
Form CS-SSO
Overflow Reporting Form
-- PART I
This form shall be submitted to the appropriate DWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number: NC OODUZ72 (WQCS# If active, otherwise use treatment plant NCIWQ#)
Facility." Blue Ridge Paper Products, Inr- - Wastewater Treatment Plarra
�--incident #
Owner Slue I'll fte Paper Products, Inr~ Region: Asheville
Cam: Mill also treats wastewater forTown of Canton, NC County, Haywood Co.
Source of SSO (check applicable) : 21 Sanitary Sewer ED Pump Station
SPECIFIC loadlon of the SSO (be consistent in description from past reports ordocumentation - i.e. Pump Station e,
Manhole at Westall & Bragg Street, etc.)-. Mokrft uvernows to Pigeon rover in cardnn. NO during and attar trood urid [bad damage amid bo repalrea
Latitude (degrees/minutelsecond): 35/32fD6 Lon+gitude(degraiWminute/second)• 8215W34
Incident Started Dt 09-08-2004 Tlrne 3:00 am incident End Dt09-11-2004 Time: 12-60 pm
(mm-dd-yyyy) hh:mmAMlPM (mm•dd-yyyy) hh:mmAM1PM
Estimated volume of the SSO: unknown > 15,000 gallons Estimated Duration (Round to nearest hour;-
Describe how the volume was determined: tluDd rMAIens, ovmhow mixed wi@r eoadwamra, mral wiume unkna%n
Weather conditions during SSO event- Hurricane Francas, record I
Did SSO reach surface waters? 0 Yes ❑Noll Unknown
Surface water name: Pigeon River
Did the SSO ra;ult in a fish kill? ❑ Yes Q No ❑ Unknown
SPECIFIC causes) ofthe SSO:
Volume reacting surface waters (gallons): unknown
If Yes, what is the estimated number of fish killed`
® Severe Natural Condition ❑ Grease ❑ Roots
D Inflow and Infiltration ❑ Pump Station Equipment Failure ❑ Power outage
❑ Vandalism ❑ Debris in line Other (Please explain in Part 11)
immediate 24-hour verbal notification reported to: DENR 1-800 number at 07.45 on 9/8, follow-up with Keith Haynes ARO
M DWG] [2D Emergency Mgmt. Date {mm-dd-yyyy): MOB-2004 Time (hh:mm AM1PM)- 7:45 am
If an SSO is ongoing, please notify Regional Office on a daily basis until SSG can be stopped.
Per G.S. 143-2,15.1C(b), the responsible party of a discharge of 1,D00 gallons or more of untreated wastewater to surface
waters shall issue a pressrelease within 4"ours of first knowledge to all print and electronic news media providing general
coverage in the county Where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a ublir notice shall be published evrfhin 1 D days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute far further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge, was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge: was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
andlor owner, a id the discharge could not have been prevented by the exercise of reasonable control.
Part II must be Completed to provide a justification claim for either of the above situations. This information will be the basis
far the determination of any enforcement action. Therefiore, it is Important to be as complete as possible.
WHETHER OR NOT PART iI IS COMPLETED, A SIGNATURE iS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003 Page 1

4-2004 07:53pm From -BLUE RIDGE PAPER
8286466892 T-068 P.008/015 F-384
VIA
Form CS-SSO
YCollection System Sanitary Sewer Overflow Reporting Form
PART I I
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN PART I OF THIS FORM
AND INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN PART I
In the check boxes below, NA = Not Applicable and NE a Not Evaluated
A HARDCOPY OF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWQ REGIONAL OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Severe Natural Condition (hurricane, tornado, etc.
Describe the "i:evsre natural condition" in detail.
Passage of Hurricane Frances resulted in record flood, overtopped flood dikes and flooded WTP.
How much advance warning did you have and what actions were taken in preparation for the event?
Activated f(Dod plan on 917 and took all reasonable precautions to prevent flood of WTP
Comments:
Blue •Ridge Paper WTP also treats sewage from Town of Canton. Will shutdown, sewage from town overflowed.
Grease (Duoumentation such as cleaning, inspections, enforcement
actions, past overflow reports, educational material and distribution date,
etc. should be available upon request.)
Men was the last time this specific line (or wet well) was cleaned? Not applicable
Do you have an enforceable grease ordinance that requires new or retrofit of grease traps/interceptors? 13Ye.0 No E1 .ONE
Have there bean recent inspections and/or enforcement aclions taken on nearby restaurants or other ❑Ye.,U No NA❑NE
nonresidential grease contributors?
Explain.
Have there beers other SSOs or blockages in this area that were also caused by grease? ❑YeD No BNA ❑ NE
When?
If yes, describe them:
Have cleaning ,and inspections ever been Increased at this location? 11YX1 No UNA LINE
Explain.
CS-SSO Form October 9, 2003 P39G z

'14-2004 07:54pm Fram-BLUE RIDGE PAPER 8286496892 T-068 P-009/015 F-384
Have educaticnal materials ahout grease been distributed in the past? 13Yes0 Na L1NA IINE
When?
and to whom?
Explain?
If the SSO occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation?
Were the iloatsclean?
--1
❑y.0Na NAONE
Comments:
Roots
Do have
QY.E
yor] an active root control program?
N.BNA[INE
Describe
Have cleaning and inspections ever been increased at this location because of roots?
❑Yell No DNA LINE
Explain:
What corrective: actions have been accomplished at the SSO location (and surrounding system if
associated with the SSO)?
What corrective; actions are planned at the SSO location to reduce root intrusion?
Has the line been smoke tested or videoed within the past year?
11Ye.11 Na BNA ❑ NE
If Yes, when?
Comments:
Inflow and Infiltration
Are you -under an SOC (Special Order by Consent) or do you have a schedule in any permit that
13Ye1 No BNACINE
addresses 1/1?
CS-SSO Form October 9, 20C13
Page 3

4-2004 07:54pm Fram-BLUE RIDGE PAPER
8286466892 T-068 P-010/015 F-384
Explain if Yes:
What corrective actions have been taken to reduce or eliminate I & I related overflows at this spill location
within the last year?
Has there been any flow studies to determine in problems in the collection system at the SSO location?
❑Yes❑ No
UNA❑NE
If Yes, when was the study completed and what actions did it recommend?
Has the line been smoke tested or videced within the past year?
Yes❑ No
NA NE
If Yes, when and indicate what actions are necessary and the status of such actions:
f
Are there In related projects in your Capital Improvement Plan?
YesO No
NA U NE
IfYes, explain:
Have #here beam any grant or loan applications for Ill reduction projects?
0Yes0 Na ONA
U NE
If Yes, explain:
Do you suspect any major sources of inflow or cross connections with storm sewers?
❑Yes❑ No
NA ❑NE
IfYes, explain:
f
Have all lines contacting surface waters In the SSO location and upstream been Inspected recently?
[]Yes[-N.NA
❑NE
If Yes, explain:
What other corrective ac#ons are planned to prevent future in related SSos at this location?
Comments:
Pump Stallion Equipment Failure (Documentation of testing, records etc_
shoul be provided upon request.)
What kind of n:rtificationtalarm systems are present?
Auto-dialer/telemetry (one-way communication)
DYes
CS-SSO Form October 9, 2003 Page 4

':54pm From -BLUE RIDGE PAPER
Audible
Visual
SCADA (two-way communiration)
Emergency Contact Signage
Other
8286466892 T-068 P-011/015 F-384
[3yes
DYes
DYea
DYes
ElYes
Describe the equoment that failed?
Flood waters submerged V1iTP and sewage pump stations, power was cut before flooding
What kind of situations trigger an alarm condition at this station (i.e, pump failure, power failure, high
water, etc.)? high level
Were notificatm)nlalarm systems operable? Yes0 No EINA GNE
If no, explain:
If a pump failed, when was the last maintenance andlor inspection performed?
Mat speclficallywas checkedlmainfained?
If a valve failec , when was it last exercised?
Were all pump -a set to altemate? 13Y.0 No WNA ❑ NE
Did any pump !,.how above normal run times prior to and during the SSO event? []YesO No Ed ONE
Were adequate; spare parts an hand to fix the equipment (switch, fuse, valve, seal, etc:)? []Yen No NfyuNE
Was a spare a -portable pump immediately available? DYCE WONAONE
If a float problem, when were the floats last tested? How?
If an auto -dialer or SCADA, when was the system last tested? How?
Comments:
CS-SSO Form October 9, 2003 Page 3

14-2004 07:54pm From -BLUE RIDGE PAPER
P.0121015 F-384
Power outage (Documentation of testing, records, etc., should be
provided of alternative power source upon request)
What is your a Iternate power or pumping source?
Did it function properly?
Describe?
When was the alternate power or pumping source last tested under load?
If caused by a weather event, how much advance warning did you have and what actions were taken to
prepare forthe event? Activated flood plan on W and took all reasonable precautions to prevent flood of WTP
Comments:
Vandalism
Provide police report number:
Was the site secured?
If YP¢ h_"'?
Padlocked Control Panel
Have there beam previous problems with vandalism at the SSO location?
If Yes, explain:
13Y.0 NoUUNADNE
No
What security measures have been put in place to prevent similar occurrences in the future? t_UY.J N.YALINE
Comments:
Debris in lino (Rocks, sticks, rags and other items not allowed in the
collection system etc.
What type of dobris has been found in the line?
How could it have gotten there?
Are manholes i -i the area secure and intact?
No UNA IJNE
CS-SSO Form October 8, 2003 Page 6

14-2004 07:55pm Frrnn-BLUE RIDGE PAPER 8286466892 T-068 P.013/015 F-384
When was the area last checkedPcleaned?
Have cleaning and inspections ever been increased at this location due to previous problems with debris? DYeJINa ONAQNE
Fvlain:
Are appropriab: educational materials being developed and distributed to prevent future similar 11Y6.0 No NA ONE
occurrences?
Comments:
Other (Pictures and a police report should be available upon request.)
Describe:
Were adequate equipment and resources available to fix the problem? Ely.[] No Ll NANE
If Yes, explain:
Ifthe problem (mould not be Immediately repaired, what actions were taken to lessen the impact of the
SSO?
Comments:
For DWQ U;;e Only:
DWQ R uesti d an Additional Written Report 13YX ❑ eq p Na NA NE
IfYes, What Additional Information is Needed:
Comments:
SSOs were result of major flood event that damaged wastewater treatment plant owned by Blue
Ridge Paper Products and also damaged sewage pump stations owned by Town of Canton. See
letter from Blue Ridge Paper Products stated 14 Sep 2004.
CS-SSO Form October 9, 2003 Page 7

14-2004 07:55pm From -BLUE RIDGE PAPER
8286466892 T-068 P.014/015 F-384
As a representative for the responsible party, I certify that the information contained in this report is true and accurate
to the best of my knowledge.
Person submitting claim: Bob Shanahan Date. 14 Sep 2004
01
Signature: A0( p-e
Tine: VP and Mill Manager
Telephone Number: 828_646-2840
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five days of first
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of this form
is completed,11 used).
Reference letter from Blue Ridge Paper Products dated 94
September 2004.
CS-S50 Form October 9, 2003 Page 8

14-2004 07:55pm From -BLUE RIDGE PAPER 8286466892 T-068 P.015/015 F-384
contact Rabe'tw� °;FkSuaftyAftrs BluBLUE RIDGE
e �e PaperProdtes inn.
Phone: (SMI 646 2flG33 _ PAPER P Et fl C) LJ C T S INC.
Ernail: Vy1Mb@hlueridgepapercom _
For Immediate Release
NOTICE OF DISCHARGE OF UNTREATED WASTE
Canton, NC — September 9, 2004 -- On September 8, 2004 Haywood County and Western North
Carolina received floodwaters as a result of Hurricane Frances. North Carolina Governor Easley has
declared a state of disaster for all of North Carolina The floods have caused the shutdown. of Blue
Ridge Papor Products' wastewater treatment plant. Concomitant with this shut down manufacturing
operations were also curtailed and no industrial wastewater is being generated. The Blue Ridge
wastewater treatment plant also receives municipal waste from the Town of Canton. As a result of
this shut down untreated waste from the Town of Canton has been released to the Pigeon River.
As of Septutuber 9, 2004, the Blue Ridge wastewater treatment plant remains out of service and
untreated n micipal waste is being discharge to the Pigeon River. The Town of Canton and Blue
Ridge Papc,r Products are working diligently to restore treatment of the Town's wastewater at the
earliest possible time. Canton NMI operations will not resume until all wastewater treatment plant
operations are restored.
Representatives of the Haywood County Health Department, the North Carolina Department of
Environment and Natural Resources and Haywood County Emergency Services have been notified
of flood damage to Canton and Blue Ridge wastewater treatment systems. These agencies are
monitoring actions to restore these services.

Form CS-SSO
?i
1 dCollection System Sanitary Sewer Overflow Reporting Form
PART I
This form shall be submitted to the appropriate DWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number: Wr'002:2 go (WQCS# if active, otherwise use treatment plant NCMQ#)
Facility: 5---0��7c"n Incident#
Owner: /A-)&7be Ste'yece-y f Al.e Region:
City: �i7i��r/.� �J.�, g6o County: ,A'e/�
Source of SSO (check applicable) : Sanitary Sewer Pump Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation - i.e. Pump Station 6,
Manhole at Westall & Bragg Street, etc.) : Z'%/J-o% o02 6%Vl� e 60eZ/2 'e
Latitude (degrees/minute/second):
Incident Started Dt: i Time:
(mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: ✓d. 00 CJ gallons
Longitude(degrees/minute/second
Incident End Dt: Time:A 30 Pm
(mm-dd-yyyy) hh:mm AM/PM
-o
Estimated Duration (Round to nearest hour):
Describe how the volume was determined: AV eala�e co vi a 19J-0 , ./�7/7AC'
Weather conditions during SSO event.. '2
Did SSO.rea.ph surface waters? fl Yes No Unknown Volume reaching surface waters (gallons): /O ood
Surface water name: - A-/�Z- T42 f_l"er
Did the SSO result in a fish kill? EJ Yes N Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
LIT Severe Natural Condition El Grease El Roots
El Inflow and Infiltration 1:1 Pump Station Equipment Failure El Power outage
rEl Vandalism 1 -1 Debris in line Other (Please explain in Part II)
Immediate 24-hour verbal notification reported to: y
/DWQ EJ Emergency Mgmt. Date (mm-dd=yyyy): ?� Time (hh:mm AMIPM): 3,®0 /fi
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete Fsi i- F 1 V
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT T"' D OF THIS FORM. M - OCT - 4 20
CS-SSO Form October 9, 2003
WATER ALITY SECTION

r !4 Tfiis
Form
�y1..1 -i Collection System Sanitary Sewer Overflow Reporting
�� „ ^,�,.�,-ham •�
PART I I
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN PART I OF THIS FORM
AND INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN PART I
In the check boxes below, NA = Not Applicable and NE = Not Evaluated
A HARDCOPY OF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DW REGIONAL OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE'REPORTING SYSTEM
Severe Natural Condition (hurricane, tornado, etc.)
Describe the "severe natural condition" in detail.
17o,o
How much advance warning did you have and what actions were taken in preparation for the event?
Comments:
Grease (Documentation such as cleaniriq, inspections; enforcernent
actions, past overflow reports, educational material and distribution date,`:.
etc. should be available upon request.)
When was the last time this specific line (or wet well) was cleaned?
Do you have an enforceable grease ordinance that requires new or retrofit of grease traps/interceptors? LTYes[-] No❑NAONE
Have there been recent inspections and/or enforcement actions taken on nearby restaurants or other ❑YesO No E NA ❑NE
nonresidential grease contributors?
Explain.
Have there been other SSOs or blockages in this area that were also caused by grease? ❑Ye No ❑NA ❑NE
When?
If yes, describe them:
Have cleaning and inspections ever been increased at this location? ❑YesO No ONA DNE
CS-SSO Form 'October 9, 2003'' ; Page 2

erials about grease been distributed in the past?
Explain?
If the SSO occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation?
Were the floats clean?
Comments:
Roots
Do you have an active root control program?
Describe
❑Yes❑ No UNA El NE
❑ Yes❑ No DNA ❑ NE
❑Yes❑ No0 'NA ❑NE
Have cleaning and inspections ever been increased at this location because of roots? ❑Yes No ❑ NA ❑NE
Explain
What corrective actions have been accomplished at the SSO location (and surrounding system if
associated with the SSO)?
What corrective actions, are planned at the SSO location to reduce root intrusion?
Has the line been smoke tested or videoed within the past year? ❑Ye No ❑NA ❑NE
If Yes, when?
Comments:
Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule in any permit that 1:1Ye,2 No ❑ NA ❑ NE
addresses I/I?
CS-SSO Form October 9, 2003 Page 3

Explain if Yes:
What corrective actions have been taken to reduce or eliminate I & I related overflows at this spill location ,
within the last year?
Has there been any flow studies to determine 1/1 problems in the collection system at the SSO location? ❑Yes No ❑NA ❑ NE
If Yes, when was the study completed and what actions did it recommend?
Has the line been smoke tested or videoed within the past year? ❑Yes No ❑ NA ❑ NE
If Yes, when and indicate what actions are necessary and the status of such actions:
Are there 1/1 related projects in your Capital Improvement Plan? ❑Yes❑ No 'NA ❑NE
If Yes, explain:
Have there been any grant or loon applications for 1/1 reduction projects? ❑Yes[-1 No El NA El NE
If Yes, explain:
Do you suspect any major sources of inflow or cross connections with storm sewers? ❑ Yes No ❑ NA ❑ NE
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream been inspected recently? Yes❑ No ❑ NA ❑ NE
If Yes, explain:
What other corrective actions are planned to prevent future 1/1 related SSOs at this location?
Comments:
Pump Station Equipment Failure (Documentation of testing, records etc.,
shoul be provided upon request.)
What kind of notification/alarm systems are present?
Auto-dialer/telemetry (one-way communication)
❑ Yes
CS-SSO Form October 9, 2003 Page 4

le
%:31-r d (two-way communication)
Emergency Contact Signage
Other
Describe the equipment that failed?
❑ Yes
❑ Yes
❑ Yes
❑ Yes
❑ Yes
What kind of situations trigger an alarm condition at this station (i.e. pump failure, power failure, high
water, etc.)?
Were notification/alarm systems operable? ❑Yes❑ No � NA ❑ NE
If no, explain:
If a pump failed, when was the last maintenance and/or inspection performed?
What specifically was checked/maintained?
If a valve failed, when was it last exercised?
Were all pumps set to alternate? ❑Yes❑ No 2NA ❑ NE
Did any pump show above normal run times prior to and during the SSO event? ❑Yes❑ No lJ NA ❑ NE
Were adequate spare parts on hand to fix the equipment (switch, fuse, valve, seal, etc.)? El Yes[] No U NA ❑ NE
Was a spare or portable pump immediately available?
❑Yes❑ No 'NA,❑NE
If a float problem, when were the floats last tested? How?
If an auto -dialer or SCADA, when was the system last tested? How?
Comments:
CS-SSO Form October 9, 2003 Page 5

Power outage (Documentation of testing, records, etc., should be
provided of alternative power source upon request.)
What is your alternate power or pumping source?
Did it function properly? El Yes
Describe?
When was the alternate power or pumping source last tested under load?
If caused by a weather event, how much advance warning did you have and what actions were taken to
prepare for the event?
Comments:
Vandalism
Provide police report number: '
Was the site secured?
If Yes, how?
❑Yes❑ NoUNA❑NE
Have there been previous problems with vandalism at the SSO location? ❑Yes❑ No NA❑NE
If Yes, explain:
What security measures have been put in place to prevent similar occurrences in the future? ❑Yes❑ No 0 'NA ❑NE
Comments: .
Debris in -line (Rocks, sticks, rags and other items not allowed in the
collection system, etc.)
What type of debris has been found in the line?
?�o�ik cl/l� G�gve/
How could it have gotten there?
ii
Are manholes in the area secure and intact?
No U NA LJ NE
CS-SSO Form October 9, 2003 Page 6

last checked/cleaned?
cleaning and inspections, ever been increased at this location due to previous problems with debris?
Explain
❑ Yesl- No u NA ❑ N E
Are appropriate educational materials being developed and distributed to prevent future similar ❑Yes❑ No �tvA uNE
occurrences?
Comments:
Other (Pictures and a police report should be available upon requestj
Describe:
Were adequate equipment and resources available to fix the problem? Yes❑ No ❑NA❑NE
If Yes, explain:
If the problem could not be immediately repaired, what actions were taken to lessen the impact of the
SSO?
Comments:
For DWQ Use Only:
DWQ Requested an Additional Written Report:
If Yes, What Additional Information is Needed:
Comments:
❑ Yes[—] No ❑ NA ❑ NE
CS-SSO Form October 9, 2003
Page 7

As a representative for the responsible party, I c
to the best of my knowledge.
Person submitting claim: Jo"J
Signature: AV
Telephone Number:
(that the information contained in this report is true and acM
Date: /rJ1Ia y
i ��';
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five days of first
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of this form
is completed, if used).
CS-SSO Form October 9, 2003 Page 8

09:37 82BB986962
SUGAR MTN
�RRRL R FAR L1FITEt SERU 1 CE, rt NC.
PH BOB 337- BRNNER ELK, NE 79664
B28-8gB--5Bi l ■ FHK 828_898-6962
Ff H CRUER SHEET
n FITE: 1®- R-84
PAGE 01
.
ieth Haynes
FRH:
FRRM: n13H Wuody - Rrea Manager, Western North Carolina
RE: ildd its newspaper
Q
Number of pages including couer sheet: [ 2 ] ® Check if
Confidential
❑ FY i ® Per Your Request ❑ Reuiew & Cali ❑
Correspondence
K
Message: THMS
Response:

1/08/2004 09: 37
82BB988962
x
SUGAR MTN PAGE 02
..... . . . . .
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This form shall be submitted to thel
SSO
D
Form CS-SSQ
Sanitary Sewer overflow Reporting Form
PART I
of the first Vnow,ed90 of
ute sanitary sewer ovedlow ( )•
Permit Number. 1!� C. S 0c) 4VC1CS# if active, otherwise use treatment plant NCMIQ14)
Facility: � �o�V-�S� t• , �ts-y� ��a lnciden" #
Owner: Rcgian.
2
city:�� d `n G t�R a,1 County _
Source of SSO (check applicable), Sanitary Sewer pump Station
SPECIFIC location of the SSO (be consistent in ascription €� , from past reports or daeume,�tatitin - I.e. p Stat-iioon. 6,
Manhole at Westall & Bragg Street, elcJ :. SQ t V `L) i J �C�
Latitude (degrees/minutelsecond): -
Inddent Started Dt: Time. 9 A.
Estimated volume of Ilia SSO: 5 00" — gallons
.t.
Describe how the volume was determined: —
11 Weather conditions during SSO event:
Did SSO reach surface waters"? ® Yes ONO ❑ Unknown
Surface water name: --
Did the SSO result in n fish kill? Q Yes EINo N Unknown
SPECIFIC oat+ee(e) of the SSO:
Long itude(degreestminute/s•jaond)-
Incident End Dt: (j -0 Tfine �Lt
(mm�ld-yyyy)- ... - _.. hti .mm APNPtM�_�_ ``-- ......_..
Estimated E)uration (Round to nearest hour):
� �����s a� y C.Y
Voturne reaching surface waters (gallons):QooloD
If Yes, what is the estimated number or fish killed?
® Severe Natural Condition �. Grease
C3 inflow -and Infiltration ❑ "urnp Station Equipment Failure
El Vandalism Peons In line, `
Roots
❑ Power outage
0 other (Please explain in Fart�*.,�('+�
Immediate 24-hour verbal nofir!cation reported to. ` `�" ` ` " "' �6 \ lJt r►t
--
DWQ ® Emergency Mgmt. pate (mnvdd-yyyy): Time (hh:mm AMIPM):
If an SSO is ongoing, please notify Regional Office on a daily basis until $SO can be stopped.
Per G.S. 143-215.1C(b), the responsible party of a disot!arge of 1,000 gallons or more of untreated wastewater to surface
waters sholl issue a pressrelease within 4"ours of first knowledge to all. print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a 2ublic notice shall be published within 10 days and proof of publication shall be provided 10 lhq Division within 30 days.
Refer to the referenced statute for further detail.
The Director, vivwon of Water Quality, may teaks onrorcoment action for S_5_Os that are ro . !fired to be re arled to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible aitematives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by fciiAors beyond the roosonablo conlrol of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part 11 must be completed to provide a justification clalm for either of the above situafinns. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible,
WHETHER OR NOT PART 11 IS !COMPLETED, A SIGNATURE IS.REQUIRED AT THE END OF THIS FORM. .
CR-SSO Form October 9, 2003 Page 1,

UT7JrI- r1ClU Ur C I-q W lUf 1:1 IOGOJ pO r-pu rT t+.V
' v�r
:�°: .•�'o� Form Ca-$SQ
Qt;oNection Syslern Sanitary Sewer oveffl Reporting Form
PART I
ANSWER THE FOLLOWING QUE8T1ONS FOR EACH RELATED CAUSE CHECKED IN PART I OF THIS FORM
AND INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN PART I.
In the check boxes below, NA = Not Applicable and NE = Not Evaluated
A HARDCOPY OF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWQ REGIONAL_ OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE; REPORTING SYSTEM
Severe Natural Condition hurricane, tornado, etc.
Describe the "severe natural condition" In detail.
5 t, r rn T M c,es
How much advance warning did you have and what actions were taken In prepwatiou ror the evcrd?
Comments:
Grease (Documentation such as cleaning, inspections, enforcement
actions,_past overflow reports, educational material and distribution date,
etc. should be available upon '
on' re hest.
When was the last time this specific line (or wet well) was cleaned?
Do you have an enforceable grease ordinance that'reyuires new or retrofit of grease traps✓interceptom? ❑.Y. U ko Q NA❑14E
Have there beet? recent Inspections andlor enforcement actions taken on nearby restaurants or oilier ❑Yet0 rto U NA E1 NE
nonresidential grease contributors?
Explai�i.
Have there been other $SOs or blockages in this areat that were also caused by grease? ❑YesLJ No DNA ONE
When?
If yes, describe them,
Have deaning'and inspections ever been increased at this location?
Explain.
CS- SSO Form October 9, 2003
❑YesO Na❑NA❑NE.
Page 2

RANE
Ravo educational materials about grease been distdbutwl in the past? ❑ Ye50 Ii`' ] D
When?
and to whom? —r
Explain?
If the SSQ occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation? .
Were the floats clean? ❑'(esu No ❑ NA ® NE
Comments:
Roots
Do you have an active root.coritrolprogram? ❑Yeses No©NA,CNlr
Describe
Have deaning and inspections ever been increased at this. location because of roots? ❑Ye. No ❑NA I]NE
Explain:
What corrective actions have been acoornpiished at the $SO location (and surrounding soystem if
associated with the ssO)?
What corrective actions are planned at the $SO location to reduce root intrusion?
Has the line been smoke tested or videced withln the past veal? uYesQ No ❑ NA El NE
If Yes, when?
Comments:
inflow and Infiltration
Are you under an $ot; (Special Order by Consent) or do you have a schedule in any permit that ❑ Yes %� No CI IJA ❑ NE
addresses 1/1?
2003 Page
C; DSO I•orm OeloBar 9, - 3

U-vzaitip rieia uperarions
kactsJ4;Vr-oufIt p.sa
Explain -if Yes:
What corrective actions have been taken to reduce or elirttinate I & I related overflows at this spill location
within the last year?
LQ-o-Tg- r�7\aAQ1,
Has there been any flow studies to determine Ill probletns in the collection system at the SSO location? OYes4 NoONA ❑NE
If Yes, when was the study completed and what actions did it recommend?
Has the, line been smoke tested or videoed within the past year? �YeZ No0NAO Nt=
If Yes, when and indicate what actions are nvicessary and the status of such. actions'
l� Q. CX-) S I� - --
Are there III related projects in your Capital Improvement Plan? OYes+� Nn©NA ❑NE
if Yes, explain: ---
Have there been any grantor loan applications for Ill roduoVon projects? OYe S.NoONA C'3NE
If Yes, explain:
Do you suspect any major sources of inflow or cross rxinnections with storm sewers? OYcA No0 NA ONE
If Yes, explain:
Have all lines contsoting surface waters in the SSO location and upstream been inspected recently? OYO NORINA ONE
IfYcs, explain:
What other corrective actions are planned to prevent future Yl related SSOs at this location? `
Comments:
Pump Station Equipment Failure (Docurnenttation of testing, records etc.,
shout be provide upon request.)
What kind of notification/alarrn systems are present?
Auto-dialer/telemetry (one-way communication)
CS-SSQ Form October 5, 2003
©Yes
Page 4

Audible
Ely"
Oyes
Vi5Uai
.
❑Yes
SCADA (two-way communication)
G� Yes
Ernergency Contact Signage
Yes
Other❑
.
DC -scribe the equipment that failed?'
What kind of situations (rigger an alarm condition at this station (i.e. pump failure, power failure, high
water, e(c.)?
QYe2 NoDNAE
Were notification/alarm systems operable?
If no, explain;
If a pump faiied, when was the last maintenance and/or -inspection performed?
What specifically was chec:kedlmaintafned?
If a valve failed, when was it last exercised?
GYesD htoONADNE
Were all pumps set to alternate?
Q Yes No.O NA D N6
Did. any pump show above normal run times prior to and during the SSO event?
UYesG No D NA DN[
Were adequate spare parts on hand to fix the equipment (svritch, fuse, valve, seal, etc.)?
L!Yesu NoDNA CDNE
Was a spare or portable pump immediately availabie?
If a float problem, when were the floats last tested? How?
If an auto -dialer or SCADA, when was the system last tested? How?
Comments,
' CS-SSO't=0[fYi q, 2.0U:t -
..
Rage 60C.'Anhpf

Power outage (Docurnehtatibn of testing, records; etc., should be
provided of alternative power source upon request) -
What is your alternate power or pumping source?
Did it function properly? ❑YeZ No❑W.0NE
Describe?
When was the alternate power.or pumping source last tested under load?
If caused by a weather event, how much advance warning did you have and what actions were taken to
prepare for the evenf?
Comments:
Vandalism
Provide police report number.
Was the site secured?
❑Ye50 No❑NA INE
If Yes, how?
Have there been previous problems with vandalism at the SSO location? ❑ Ye�D No ❑NA ❑NE
if Yes, explain: .
What security measures have been put in place to prevent similar occurrences in the future? ❑YesO No ❑ NA❑ NE
Comments,.
Debris in line (Rocks, sticks, raps and other items not allowed in the
collection system, etc.)
What type ordebris has been found in the line?
How could it have gotten there?
Are manholes in the area secure and intact? ❑YeSD No ❑NA ❑NE
CS.SSO Form October 8, 2003 Page b

area last checkedideaned?
and inspections ever been increased at this location due to previous problems with debris? OYez Nu O NAO HE
Explain;
Are appropriate educational materials being developed and distributed to prevent future. similar MY0100 No0Nh11NE
occurrences?
Comments:
other Pictures and a police report should be available upon re usst.
Describe: _
Were adequate equipment and resources available to fix the problem? DYesQ NoO NA ONE
If Yes, explain:
if uie problem could not be immediately repaired, what Fictions were taken to lessen the impact of the
SS4?
Comments:
For DWQ Use Only:
DWQ Requested an Additional Written Report:
IFYes, What Additional information is Needed:
Gommenis:
CS SSb Form October Q. POM
❑YOSO NOONADNE
Page 7

q-rb-a4
Person submining claim:
�, Auo
Title: ..`�cA ...
I� �^o•-i
Signature.
Off
Telephone Numbar. "anal (}'Tice within five dam aua kx %t
roriate division Reg i�tU'tinic ea7try
AnY additional ioforrnation desired to be submitted silouid be sent to the aPP
n�mted vr11w V '.
knowladgo of the Sac? with mterence to the incident nultlbc' (the incident nurn is un1Y
is completed, if used).
Page 8
Vs.gsq Form pctoGer 9, 2003

Collection System Sanitary
This form shall be submitted to the appropriate DWQ Regional Office within five. days
the sanitarysewer overflow (SSO).
ber : 03&sO CAB 2-
Permit Num
%d � — (WOOS# if active, otherwise use treatment plant WCrt/04)
Facility - t C �1dLl lIncident #—
Owner: Il T t Region v
City eA County. ---
Source of SSO (check applicable) ' 'S Sanitary Scwver ❑ pump Station
SPECIFIC location of the S80 (be consistent in desGiplion from past repotts or d(>cum anon - Le. Pump Stalior) 6. inQrK
Manhole at Westall &Bragg Street, etc.)
Latitude (degreeslminutaallsecond): t_orng[tude(degrees/minute/s.-eond)-
Incident Started Dt: L- Time: J?M- Incident End Dt: Time.
mm-dd-yyyy (aim-.dd-Y&Y1 .._. _.. hb:,►nmAftlpM.. _
Estimated volume of the SSO: i�h }�►16rai Ai id gallons Estimated Duration (Round to nearest hour):
Describe how the volume was determined;, f D i7
Weather conditions during $SO event: t
Did SSO reach surface*ters? M Y CINp❑ Unknown Volume. reaching surface waters (gallons): 6t.0
Surface water name: ----�
Did the SSO result in a fish kilt? Q Yes �No Unknown If Yes, what is the estimated number of fish kaled?—
SPECIFIC caw*v-) of the SSO:
Severe Natural Condition El Grease ® Roots
® inflow -and Infiltration ❑ Flump•Statfon Equipment Failure ❑ Power outage
El Vandalism Debris in line(� Other (Please explain in Fact11))��/
{�{immediate 24-hour verbal notification reported.to- - f�.g + Ia — e_S
DWQ El Emergency Mgmt. Mete (mm-dd-yyyy):- Ig -,A Time (hh:mm AM/PM):..
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Pere S. 143-215.11C(b), tic responsible party, of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all. print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the. Division within 30 days.
Refer to the referenced statute for further detail.
The Director, VIvI6lOn of Water Quality, may tal,,o enforcement action for SSOs that . are reuircd to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; ar
2) the discharge was exceptional, unintentional, temporary and caused Uy factors beyond the roo,cnabfo co trot of the Pennittt?e
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control,
Part 11 must be completed to provide a jucfification clslm for either of the above situnfinns. This information will be the basis
for the determination of any enforcement action, Therefore, it is important to be as complete as possible,
WHETHER OR NOT PART It IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-g80 Form • October 9, 200$
Page 1

4 04:57p
Field Operations (8281687-3074 p.3
Form CS-SSO
Collection Systern Sanitary Sewer Overflow Reporting Form
PART I I
ANSWER THE FOLLOWING (QUESTIONS FOR EACH RELATED CAUSE CHECKED IN PART I OF THIS FORM
AND INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN PART I
In the check boxes below, NA _ Not Applicable and NE = Not Evaluated
A HARDCOPY OF THIS FORM SHOULD BE SU13MI17ED TO THE APPROPRIATE DWO REGIONAL OFFIGF
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Severe Natural Condition (hurricane, torn ado, etc.
Describe the "severe natural condition" In detail.
How much
Comments:
waming did you have and what actions were taken in pre trututli i far flae event?
J, - . - _ 1 . 1. I^ -,1f. „ i-%. 'r^' a n
When was the last time this specific line (or wet well) was cleaned?
Do you have an enforceable grease ordinance that requires new or retrofit of grease trapstinterceptors?
Have there been recent Inspections and/or enforcement actions taken on nearby restaurants or other
nonresidential grease contributors?
Explain.
nc�i e\4�t .
DYes-- No❑NAQNE
Elymo NoUNAONE
Have there been other SSOs or blockages in this area that were also caused by grease? YcsU Wo CINA ❑NE
When?
If yes, describe them:
Have cleaning and inspections ever been increased at this location? ❑Y® No11NA1:1NE
1=xplain.
CS-SSO Form October 9, 2003 page 2

4 04:59p Field Uperations
anal rnateriais about grease been distdbutet{ in the past?
When?
and to whom?
Explain?
18e8J B87-3U'14 p.4
If the 880 occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation?
Were the [bats clean?
Comments:
Roots
Do you have an active root control program?
Describe
QYOD N<C]NAENE
l Ye,L] No 0 NA ❑ NE
CIY,sD NO©NACNE
Have cleaning and inspections ever been increased at this location because of roots? Ye,D No NA NE
Explain,
What corrective actions have been accomplished at the SSa location (and surrounding system if
associated with the SSO)?
What corrective actions are planned at the M location to reduce root intrusflon?
Has the line been smoke tested or videoed within the past year? UYes� Not —DNA NE
If Yes, when?
Comments,
Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule in any permit that ❑ Yes NoIhlAMN6
addresses Ul?
C&SSO Form October 0, 2003 Page 3

'es:
actions have been lakes to reduce or elinurrate I & i related overflows at this 56111ocation
within tiie last year? Ic a „ 2/ r ' r
Has there been any flow studies to determine UI problems in the collection system at the $SO location? 11YesEl No MNA ❑NE
If Yes, when was the study.complated and what actions did it recommend?
Has the line been smoke tested orvideoed within the past year? �YesU No❑NA11NE
If Yes, when and indicate what actions are necessary and the status of such actions'
Gqa t'vs Lt t P u (V-\� P--2 rviuo-cX
Are there III related projects in your Capital Improvement plan? C1 Y,,.D No©NA ONE
If You, explain;
Have there been any grantor loan applications for Ili reduction projects? 1JYes0 NoONADNE
If Yes, explain:
Do you suspect any major sources of inflow or cross cerinections with storm sewers? QYest—r NODNACINE
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream been inspected recently.? CIYedJ NOCINAC]NE
If Yes, explain;
What other correctivo actions are planned to preve I nt future UI related SSOs at this location?
Corrtmer+ts:
Pump Station Equipment_Failure (Documentation of testing, records etc.,
shoal be provided upon request.)
What kind of notification/alarm systerns are present?
Auto-dialer/telemo ry (one-way communication)
CS-SSC Form October 5, 2003
D yes
Page 4

L-s Audible Yes
Visual Q Yes
El
SCADA (two-way communication) Yes
Emergency Contact Signage Yes
Other ❑ Yes
Describe the eqi ipment that fatted?
What kind of situaflons trigger an alarm condition at this station (Le_ pump failure, power failure, high
water, etc.)?
Were notification/alaml systems operable? -' — ❑Y Z No ❑ NA ❑Nz
If no, explain:
If a pump failed, when was the last maintenance anchor inspection performed?
What specifically was checked/maintained?
If a valve failed, when was it Last exercised?
[JYeD N4❑NAE]Ne
Were all pumps set to alternate? 1�
Did any purnp show above normal run times prior to and during the SSO event? Q Yes+-� No NA NE
Were adequate spare parts on hand to fix the equipment (switch, fuse, valve, seal, etc.)? UYesQ No ❑ NA ONE
Was a spare or.porlable pump immediately available? . LiYesa NoUNA ❑NE
If a float problem, when were the floats last tested? How?
If an auto -dialer or SCAM, when was the system last tested? How?
Comments:
CS-SSO Form (k ther 9, 9..003 � Page 6

t828JE87-3074 p.7
What is your alternate power or pumping source?
Did it function properly? ❑Yes❑ NoUNA❑NE
Desi;ribe?
When was the alternate power or pumping source last tested under load?
If caused by a weather event, how much advance warning did you have and what actions were taken to
prepare for the event?
Comments:
Vandalism'
Provide police report number:
Was the site secured?
if Yes, how?
❑Yes❑ No❑MA❑NE
Have there been previous problems with vandalism at the SSO location? UYes❑ No❑NA ❑Nt=
if Yet, explain:
;What sewrity measures have been put in place to prevent similar occurrences in the future? ❑Yes❑ Nv❑ NA❑ Ni:
Comments:
Debris in line (Rocks, sticks, raps and other items not allowed in the
collection system, etc.)
What type ordebris has been found in the line?
How could it have gotten there?
Are manholes In the area secure and intact? No ❑NA ONE
CS-SSO Form October 9, 2003
Page h

9 u�rsoap rieio uperarlons
,e area last checked/deanerl?
l O,G010a r-ou r-r r .0
nave c,eal nag and inspections ever been Increased at this location due In previous problems with debris? 0-rWO NUID NAONE
Explain;
Are appropriate educationei'materials being developed and distributed to prevent future similar CJ YZ No 13NA ❑NE
occurrences?
Comments:
Other (Pictures and a police report should be available upon reguest.).
Describe: _
Were adequate equipment and resouroes available to fix tho problem? ❑Yes©NoCJNa ONE
It Yes, explain:
If the problem could not be•Immediately repaired, what actions were taken to lessen the Impact of the
SSO?
Comments:
For DWQ Use Only:
DWQ Requested sh p Additional Written Reort: ❑YesQ NoONAONE
If Yes, What Additional infonnaiion Is Needed:
Comments:
CS-SSO Form October 9, 2003 Page 7

Person submitting clalm:
Signature:
hone mUer, aa (_ tonal office within five days of first
ielep �lS� of tttis tCxut
ro date t]ivisioen Re9ed when vl�-i U'ao.1, - entry
Any eddWonal info m-3 with reference c the n,Ci� jed 5t you �a�' (tl sent
cicient number is un1Y y
knovA,3d9e of th
is completedi if used).
Page 8
October 9, Z00
G5-S5q Form
3

Phu;w 82s4m-4685
Fax
Tor KOM Haynes NO DEW Frbrllr David SmRh
Fm DWM Oar 1, 2004
Irlmrurr prim, 4 • Lb
M* Ogodlpw Rmxxt farm ql:
13 e1 13 For Rwlsw 13 P Cm nr*nt 13 Pkw" hooky 0 irAw" Rncyci.
H Kaidh
1f you have ov quedons Om me a cog
DOV4

WATER QUALITY SECTION
Form Cs-sw
Wlection SyOm Sar*M Smr Ovarfkw Reporting Fora,#
PART I
Ttda form shall be subn*wd to the pppmpde* t)wQ F?aolonsl Ofk* wMn.fare daysofttte•fttst knowiecigs of
tfw sarlitaty WAW OYSMOw (=).
Pwmk Number: NC O025321 (VWM if active, cow wloa uma teatner4 pleat NC&X*)
FvAtf.
TOM of oyt**Wft wVTP Inckdent # 1
onnsr. Town Of waynEw" fin: VM
may; wr yr !.
Samoa of = (chaK* aPplObb) : © Snnkwy Sewer 13 Pump SWm
�Qurrty: rtnywae�r
SPECIFIC Wdion of ttw SSO (be mwisl ent In climm4 un from pat rapom a dart wntatiort - I.& Pump Sbtlon s,
Mwft* it Westol & Bragg SkaaL etrw) : R•rwdlralrs r k�ouwf eaarw�rw.rria.n...Pfne
IrrJdsrrt awwwd EX 09-27 2004 Thee: 11,00 pm Ino mm lard CCW28 2004 . B:po pm
owt dd-ftw) hhmm AWWl (MMAMWw Irdxgm ArrUM
Batlmmed VOW* Of that SS4: 22'8w W&M Ind, Dundion (Rotund to nm,,a fw, 19
OeeptbQ i►gAs tfle rrUltrtriN weirs de6attnlned: "'�""'''�`�'ra =+»-w.seow�+.
VVa Ww condiliirre durxV WO ever+r t ra+ri RWn EvWd-
CW sso reach surraw waters? >js Yay llwo lllAlkmw volume macs wffa e w mars (peso m)• 22,8OD
sundae wafer names end Creek .
pid the SSO result hr a ftah lilk? O Yes Q No ❑ Unknown tr yes. what h tl7a eeUmpopd r,udrlber CF ttatr Hn
SPECIFIC t-ccaluse(s) of the SM
E) Severe N tw l Cendillon Q Grasse 13 kadis
❑ hA w and InMkaWn ❑ Pump SWOM Eq *mw nl Faflurp 0 Prawer aftge
❑ vandalism C1 0abda in Fine C] Omw (Pleaaa eq*dn In Pelt Ir)
ln.n XWv M-hour varbal noes cotton rWr rleo 10 Kgft 11a
al ENVO E3 Emar> wwY mamt. Data (mrn dd yyyyr 0 ZW Thnw (hkmm ALQPM): t: W nm
if an $SO is cng r*. please no* Regional Oftfccs on a daily basis until WO can be atoppW-
F`ar G.S. 143-215AC b), d* n"Ootrslble�af a ddiartoW Of 1,000 0dkft Or mare of ur*allsd WHAWOW to MVWO
wa%m abaft Issues a rokown d !fret taraiMetiDe to petnt and alacdotdc rwNrg trre¢a pravidktg pataral
emmvVe it fire county m barge vvpmred. Whsn 15.000 gal{onv or mere al ur*vsfed wader rrders =rft e
wetem a fie published
*W be wthin 10 days and P10 of pubkmUan &W be provided to the Dhrtabn within 30 .
Raft- m the atstum far Urrffiar dqW.
The DkDdtor man et Water Qua!Ry, my tako errforgertr d action far 88M ttrtrt we MW&Ld to be Wqo to DIAston unim i
in dKwMkMMdjhML
1) Ow discharge vres t suaed by aevede n IMI oorrdltlorls and them ware rto MMI1198 *Wis#vag th ttm disoilri W. or
2) U* discharge was except wW, uninterdlarral. tarrrporay and couny by factors Wwond to r bfe wnud of" Partni w
*MVor riwnw, amd the d odwq *VW ndrt Have barn p wmrftd by the axwctae of ramwwbfa ow*x t.
Part Il rnuat ire canil*%d to provide a )trattflcptlon Jahn for eXhar of ft above al4rot qw, That: IRfomiatian wilt be the basis
for the determiradon Of any enforcement ecOw. ThatylM% it to Impwbwd to be as vxrWiets as posatbla.
vrrit [Mg qR NOT PART If IS COMPLETM. A St 3NATLRE 1S REQUIRED AT THE END OF TH[s FARM,
CI34030 Furor Ock9 r 0. 2003 Page 1

00
Form CS SSU
lieFCollec &m Systam Sanitary Sewer Overflow Reporting Forth
PART I I
ANSWER THE FOLLOWING QUFS"I'K*B FOR EACH RELATIM CAUSE CHECKIM IN PART I OF THIS FORM
AND INCLUDE THE APPROMUkTE DOCUMENTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING SE OF THE S.SO AS CHECKED IN PART I
_ _-_ TtJ'1'HiwCAU
In the d*ck boxes below, NA = Not Appkable and NE = Not Evaluated .
A HARLICOP'f OF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRWTE DWQ REGIONAL. OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROWH THE ONLM REPORTING SYSTEM
Severe Natural Condglon f hurricans, tprnat#a, etc.
0escdbe the "aavere rag ARW conff orf In dull.
Heavy Rain due to Tropical Sh m 1 Hunicane Jeanne _
How much edvwm wwNrvg did you have and what aefto W*M Ui*n in prepmagm for the evens? ".�. .
1-2 days
+Cm m gm
Ow kw duo ft heavy rM ftMd m Tum Of a Jur*Aak a SuWanr OMM raven Or Wayrw,ar a Loks imohmam Aeee 7d* Sm w won sy%WW
When was the last tlmp thb spWk Ina for Wet welt) win charted?
bo you hive an 01foroeahte gmam otdkwnm that raqulm" new or nab llt of gmaar, �7 ❑Yt� 1Yo 4.JNA urfE
l 8tere bean nxm t &mpacbms arAby enfOrVWnerrk mtiorm taken on nay restmuertta or other
norassicbmtIal grow* 4anlrrbutera7
Have ttt m been t thar SSN or bloekaW in ihls area that wme elaa caurred by Umom % ljym Na UNA 0 N
1tYh*n?
Yea. deacxlpe Num"'
Hsva afsarib end lnapee oft www been kKnosed at lhlo kwppm4 W NA NE
QSP,9 Form OctoberS.2003 Papa 2

0 gftd 'a mvapo t=.4 oS9-Bo
'(Pew► ti vo olds m e1
uuo# etgt Ja tiros opmpme um" p Aw sl uqumu VmWLq ap) mWm Rapp" wa a emmmW qV M+ Ogg MU)o Uf
3*w ►o eoyp i eoe Awdde eta %wm eq pirow pomwwm aq oq Plop uonmuqm lWomuow Aw
, :s
!7 9 - I-) r :MHO w.wp Bumpu"

—�,Oc)qO2,03�
* Permit: IWQCS00218 Find Permit
Facility Name . lNewland Collection System
Owner: iLoyvn of Newland N
City: Newland
* Report Type: C 24 Hour 0 5 Day
* SSO Start Date/Time : (mm/dd/yyyy 9MW 101.00 AM
County (if different from above) --Select Value--- I'
* Location of the SSO Influent Pump Station
Page 1 of 1
Coun
Regi,
* Estimated Volume of SQ
City (if different from abo`
Did SSO Reach Surface Water: (=� Yes C No C, Unknown Vol. Reaching Surface Wat
Waterbody : North Toe River - 7-2-(27 7)
Other Waterbody : _ Conveyan
Did SSO result in Fish Kill: C> Yes 0 No 0-!' Unknown
*Report Received By: Reid, James R
Regional Contact : Haynes, Keith.
Reported By: Lewis, Cecil L.=`
First Name:
Middle Name:
Last Name:
Specific Causes :
Estimated Fish E
* Date/Time : (mm/dd/yyyy hh:m
Date/Time : (mm/dd/yyyyhh:m
Date/Time (5 day only) : (mm/d
hh:m
Pho
Chi Severe Natural Condition r Inflow and Infiltration F1 Vandalism
C Grease F-1 Pump Station Equipment Failure r Debris in line
r Roots r Power outage r Other (Please explain in Part II)
1=finish Saveand Cont u
http://bims. enr.state.nc.us:7001/selectOnePermit.do?id=66AN2CF000MT4DE4AXUBG 1... 9/17/2004

61
I

Incident in Avery County (BANNER ELK) on 09/18/2004 08:22:24 PM
Page 1 of 1
ken bv: J Peters
Date Occurred: 09/18/2004
NC Division of Emergency Management
Emergency Report Form (Rev 2.0)
Date Reported: 09/18/2004
Time Occurred: 09:36 AM
: 08:18 PM
Reported by: Danny Clark
Agency: Banner Elk Water and
Phone: [phone]
Sewer
IlCounty: Avery City: BANNER ELK IIEM Area: W 13
EVENT TYPE
Weather Event:
HazMat Event:
Wx Event Name:
HazMat Class: N/A
HazMat Mode: N/A
FNF Event:
Non-FNF Event:
SAR Event:
FNF Type:
FNF Class:
Fire Event:
Complaint:
OTHER EVENT: Sewage
Event Description: Approx 9,000 gallons of sewer spilled into White Head Creek from the Elk River Pump
Station on Banner Elk HWY due to heavy rain. No drinking water effected and no fish kill.
Approx 2,000 gallons of sewer spilled into Shaeneehaw Creek on Old Turnpike East due to heavy rain. No
drinking water was effected and no fish kill reported.
Attachments:
Event Location: Banner Elk, NC
Latitude (decimal degrees ) (NC inland range is 33.840 - 36.588 degrees. Values outside these parameters may
be used.)
Longitude (decimal degrees) (NC inland range is 75.460 - 84.322 degrees. Values outside these parameters
may be used.)
USFS Block -Square -Point Svstem: Block= Square= Point=
IIRRT Request: No IIRRT Mission No.: IIRRT Team Number: II
COUNTY AGENCIES
LEMC: SO: PD: LFD: CHealth: Sewer: PWRK:
Other Local Agencies:
STATE AGENCIES
A/C: SHP/SWP: Env. Mgt: Water: DRP: CAP: DOT: DMV:
Other State or Federal Agencies:
Notes:
EM Hours:
SAR Hours:
Call #:
http://149.168.212.171EM_live/EMReport.NSFlb66533df2a86c4Ob852566e 1007f74l dIdO... 9/19/2004

Collection System Sanitary Sewer Overflow Reporting Farm
This form shall be submitted Ilo the appropriate DWQ Regional Office Wain five daysof the first Wowi&dge of
the sairtttnry sewer overflow (SSO),
Parrett Nuanher :
CWQCSP If active, otherwise use h+eatrrteitt plant NCNVt]#)
Facility Incident#
Owmer. .ill' ✓ ... ._.
Region:
city C lead' r,-, .. caursty;
Source of SSO (t hwolt applicable) : L�1 c yr `aiey Ill pump Station
SPECIFIC kK aiion of the SW (be conslstani In do from past reports or n - La.
Manhole at Westali d, Bragg Street, ate,) : < < � �
L alittWo
d(dsUr&ndnueyemmd):
InCftMSated0tQZ'/ -Q`' 'n 1 I�nItt"titrd►�ctbttdEe0r nt�mch�-Ll1t®l2seeo0ot�•
Tim
cmm•W-WM � hhMm � (rnm ddJyyyy) WWM grdyF'lut
EsUmatod volume of the SSO:
a gallons
Describe how the volume was determined:
Waether condiiforis during M0 event -
Did SSO reads surface wit m? QyYas❑Null Urk-ric wn
Surfam water name: ) ---
Rid the SSO result in a fish W11? Q Yea ❑ Na �nknown
Estlmeled Duration (Round to nearest b
Volume sacking lsurfaoe watats (Denture): �
If Yes, what Is the estimated number of fish id
SPECIFICan
) of the 5W
SeVere Natural C )nditlon ❑ Growe ❑�toofs
❑ Inflow and Irrtdhatlon ❑ Pump Station Equipment F'aAunt ❑ Power oubve
0 V®ndetlsm ❑ Debris In Oro ❑ Other (Pleases explain in Part It)
Immediate 24-hour verbal notilica6an reported to-: 44 21.'
awe M EmerOertcy Iltpnn Date (mu
*dd-M) Time (hh:rnm AM1PAM:1aI2/3".
If an SSO Is ongoing, please notify Regional Office on a daily basis until $SO can be stopped.
PG.& 143 216.1 C(b). the rasponslble party of a discharge of 1.00 $.lions or mono of untreated wastewatar to surface
vvatans afutli issue a lease within 4&h0ur9 of first Imnwladpe to all print and olec h7mlc stews media providing general
c W"a in the cminty� the 0is"rge occurred. When 16,i W gallon$ or more of untreatad waskmolar eaters surface
water, a public notice shall be published within tU days and proof of publicatlon $NO be Voted to the Ulvislon wiitdn $4 days.
Refer to the referenced statute fcrfurtherdete►Ii.
The Nrgdnr. Division of Water Ouailty, may take anfarcemant action for SSOs that ace raquired to be reported to Division unless it
is demonstrated that _ .-
1) the discharge was caused by severe natural cotmditions and there vans no feaisli le altemadvvas to the discharge; or
2) the d1settarge was exceptional, unintentional, tamporary mid caused byfaaors beyond the reasonable control of thin Fbnrtitfee
andfor owner, and tha discharge cuutd not have been prevented by the exw dw of reasonable cant ml.
Part 11 must be completed to provide a )tsllflcatlon claim for ettber of tlta above sibotimm. This irdnmrat'nn will be the basis
for the determination of any anforcament action. Therefore. It le important to be Ste complote aS possiWa
WHETHER OR NOT PART 11 IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9. 2DO3 Page 1
FSEr
-CED IE
44 2004
WATER QUALITY SECTION
ASHEVILLE REGIONAL OFFICE

23 82BB27062B JACKIE EDWARDS PAGE 03
Form CS-SSO
CoPecdon System Sanitary Sawer Overflow Reporling Form
PART I
This form shall be submitted to the apprepriets DWQ Regional Office within five d9ysOfthe first kWM&dge of
the smltary sewer overflow (SSO).
Parmit Number: l d'J (WQC" If uWAL othwMao use trugtrnent plant NCNVC )
Facility. — Incident ff
Owrtef' /ecr
Region: bk
Source of SSO (check eppficabre) �Sanitery
�Sewar0Pump StatIon
SPECIFIC t ofthe {be ttln �
s Man" at Westall &Bragg Seetair-): 1?m e e Ymt aw -V,�
tanda (dagreealminutersecand): Longitude(degreaalrnirruon
Incident StwW DL. Q2,17- Q'V T1rr�; r /¢ Ircidant End Al •ram- dy Tim
orn"Id-yyyy) hhsrmr NWN tmnrdd yYyy) t rrvrr AIArPM
EaBmated volume of the SSO. gagan s Estimated Duration {Round to nea ng harr)r
r
Clesoribe how the volume was detenrdned:
Weather conditions d6n0 SSO *ar��ra,• 2FA7 ,-�. _.
aid S i] reach surface rs7 ®YesONa Unkrxswn Vahrme reaching surface waters (gellom):
Seaface wow name,, .&"A — — --
Dud the SSO result In a flah ki07 ® Yes ❑ N4 -Unknown If Yes, what Is the estimated number of fish idifew
SPECIFIC cb the Sao:
Natural Condition Grease ❑ Room
0 Inflow end Intifb-ion ❑ Pump Station Equipment Failure 0 Pvmr m t ,
13 Vandallam ❑ D b is in Ilea ❑ Odw (Please eilaln In Part Iq
Im 24hourverbal na0c itlon reportedlo! /e •vas Cf%n.� Alf _ _
2 t7WO L1. �' t. Date (�d-y9yAA-17-D ' Time (hh:mm "-j
If an SSO Is ongoing, please notify Regional Office on a deify basis until SSO can be stopped,
Isar G.S.143-21fi.1C(b), the resporrsiWi arty of a disdrwnp of 1,000 gallons or more of untreated wastewatwto surface
waters shall laaue a rays release aIn 71B-hours of find kro ec� ge toad print and elocumle. news media providing general
ooverape In the county ie schar+ge oc mrmd. Whom 15.000 gallons or more of untreated vmtawater enters surface
Waters. a pub{f� nOtlGenotlae ahaff be published within 10 days emi proof at pubnpdton shed be provided to the Divlefon ufth 30 days.
Refer to the reteranaed statute for further detati.
The Dbr ; l7hrtaIon of Water Quality, awy take enibrcernant action for $SO& that are rquked to be reported to Divisfon unlesa it
Is d2Mpsbytad that
11) the discharge was mused by severe natural conditions and them wera no re"blrr aftematives to the dlsehargm. or
21 the dlsoherge was exceptional, uninterd onel, temporary and caused by factors beyond the reasonable control ofdre F43, ore
andforowner, and the dlsoharga could not have been pmvmAed by the wwrelse of reasonable contral.
Part II must be completed to pr Wde a jusiff7cation claim for either of the above situations. This Infnrmarinn will be the basis
far the determination of any enforcement action. Therefore, it Is important tb be as complete as pow bW
WHETHER OR NOT PART 11 IS COMPLETED, A SIGNATURF IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 8, 2003 Page 1
DECE�V[
S E P 2 4 2004 ID
WATER QUALITY SECTION
ASHEVILLE REGIONAL OFFICE

14: 23
82BB2i0628
JACKIE EDWARDS
PAGE 04
� Farm CS-SSO
_ C01l000n System SanitarySewer Overflow Deporting F!cwm
.. PART I
This form shaA be submitted to the (SSO). appropriate DWQ liegfonsl pf W hi of the first Jcnnwiedge of
the $artitefy sewer overflow (SSO).
Remtlt Nuntw: [ridr]�p']' .
w �(yVQCS}# If adhra, othBrvvi9e use tneehtrertt plant NCNVO#)
FaofNty: '
Owner. C�feL.,i. r, fncidant*
t3agiws 1g--
Sorrnab of SSO (chrx* applicable); L3
ry
SPECIFIC lvcatfon ofthe= (be gonsis nt in des � it
1Vtanhole at Weslal A Bragg Sb•eet, etr-) : ^
Laftde (degrae6JmKXWt sW m -
Incident Started DI: Tim
{mm�d yyyA hhj=AhVM
Esfknated volume of fhe $$O: gallons
Describe haw MG vofunha was determined:
Weather Conditions during SSO event.
CourrRy:
❑ Pump Sfailon
L0n9 (ftraadminuk0"oondp
incidont End DLQ-T•2—_ Time C1
I� hfrsnm AkWM
Estimated Duratforr (Round to n,an a hour):-.—�
!]id SSp rgecif atRfalSe waters? � ❑ �]
,+� Yet: No Unktrawn Volume reaching surfam wwaters (gallons):
-%R1b0H water name: �
Did CI ICL result In flth fdtl? ❑ Yee ❑Nd mown If Yes, A40 ie the eellrmtml number of fish 101edR SPIECi1=1G cacrjgj4ftheSSO: -
(��SQvata Natural Condition ❑ amm'a ❑ Roots
❑ Inflow and Infibration ❑ Pump Station E4u]ipnent Faiiura ❑ Power outage
❑ Vandalism ❑ Debris in One ❑ Other (Please explain in fart Il)
Jmmediate 244vur varbai nogtication reported to: sr
2 dWQ 0 D"Ver -Y mgt. Date (mnrdd yyyy):g27`ZZLV'' Tirrb (erfr mmANUJ'
if an SSO Is ongoing, please notify Regional Ottice on a daily basis unal SSO Can be stepped.
G.S.1�3 T1.1C(b), the rasporsibla pa�py of a c&atdfarga 1,400 gatloas or more of anh'agped wasinwaierto aurtieae
Watara shell tssua a r� release n d&hours of first ►apvrfedga to a1j print and electronic craves media pmVid ing ooveiage in the cau* Q"g ischarge ecaerrrsd. Wheat 15,000 gafa0ns or more of untreated wastawater enters surfaces watara. a Publonotice shall be published within 14 days and proof of ptrbli=tlon shall be ptuvided to the Division within 3o days.
Rdfar to the raferencud stubAS flu further defa!!.
Tho Dfrermr, Division of water Quality, ft,&v takD enlibruement ovon for SSM that are regidred to ba reported to Division unless it
11} S-onat"did then —
1) the discharge was caused by severe natural conditions and Brere Were no feasibis atiernativas to the disettarge; or
2) the tlfsormne wa$ wmptltxrar, unintentional, tomPorary and mused by factors beyaW the reasonable, c oniml of the Pemthtea
and/or owner. and the discharge could not have been prevented by the exerdse q reesomeble control.
Part 11 must be completed to provide a )ust[Reation eiatm for either of the above shuat;om Thin irrt'onnation whiff be the basis
for the deteirnlrtation of any enforcement aetinm. Therefore, it is Important to be as ovtnpiets a$ paestbla.
WHUHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CSSSO Form October9. 20113 Page 1
SEP 2 4 2004 D
WATER QUALITY SECTION
3HEVILLE RRIMMAi nt=mr

82BB27062B
JACKIE ED14ARDS
PAGE 05
Form CS-SSO
Colle0011 System SOrl" Sewer Overflow Reporting Form
PART.I
This form shall be submitted to the appropriate DWQ Regional Office within flue tlaysof the f(rsi knowledge of
the sanitary sewer overflow (SSO),
Permit Num"r: A-Qa! CV ?J1. 7_ QCSA If acflve, orf,anise use treatment plavrt NCMQ#)
aiv a �r.✓ ,f/
CRY._� ..A�irl - .. CCenr on:
Source of SSO (duck applicable): Z SanRerySew pump btalfon
SPECIFIC k=Ibh of tiro S30 (be cardaWt in desaaipam [rim
Manhole at Washall & armo Sheet. aft),
r .er,rc.. (deprhaehrJrhhlrrutalsecor►d):
Incident Started Dt;%�"�" AW tea,
(r^-4 yYm hh:mm AMB'
Estimated volume of the SsO: _ gallons
Describe how the volume was dotarmtned:
Waadw oonditlone during SSO weennt� .111""Oc&AL-- r �
D1d SSO mach surface vX7 0 Yes❑Nou-r Unkwm
Surface water name: ��
D1d the Sap r suit In a 11sb idl7 ❑ Yes Q Na aU-nkrx.
SPECIFIC cause the S,a .
- Le.
►-arrgtlixte(degreeoimltnrce�secar�.
Irlcldl3nt F.rhd �� � ` �� Tirr>�L��;
( 37YYi hhanm AMPM
Elmatad Duralian (Round to nearest±w:)�_.,
volume reaching surfaw waters (gallons):
If Yes, what is the estimated number of fish Mad!
a sever>a Natural CDnAkM ❑ Greasy ❑ Roots
❑ Inflow and Infdtratkhn 1.n_.I pump Station Egtr rant Faflum ❑ Power outage
Vandalfam ❑ Debris in line ❑ oew (Pleas& a*wn in Part II)
Inm edlate 244m3ur verbal notklcatlon reported to: - &
[;1.—DWQ 0. FmwVancy MgmL Date
Time (hh:mmAN "-4?
9 an SSO is ongoing, please notify Regional Office on a daily bwls until SSO Can be stopped.
P& O.S. 143.215.1 C(b), the responsible party of a discharge of 1.000 gallons or mare of untreated wastewater to auftce.
waters shall iasue a rereaee within 4&hours of first knowledge wall print and oledroNc newe# media providing ganerat
caverrrge In the eounty�sclhage Occurred. When 1S= anions or more of untreated wastewaterentarx surraoe
voters, a public notice shall be published within 10 days and proof of publi:atlan shall be provided tQ the DIVWon within 80 days.
Referto the raWancmd statute fro further Metal!
The, Dfrecto; Dh&lon of Water Quality, may take enroraernant notion for BSOs that am mqulmd to be mport&d to Division unless it
is deahonstnhted that:
t) the discharge was caum d by swam natural conditions and there wom no faasibie altornaWn to the discharge; or
2) the discharge was exceptional, unlydehikx al. temporary and cauvod by factorts beyond the reawnabla control of trio Pwmlttee
andfor owner, and the discharge could not have been promted by the exerdse of reasonable control.
Part it must be c ornplated to phwide a Jus5fication dalm for aitlw of the above aimatImm, This Information will be the basis I
tj for the datQmhination of any enforcement action. Therefore, it is Important to be as complete as posstble.
WHETHER OR NOT PART If IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS I:ORM.
CS-SSOForm October 0, 2003 _._.__.... Para I
D E D
S E P 2 4 2004 DD
WATER QUALITY SECTION
ASHEVILLE REGIONAL OFFICE
W; ` 4

14: 23
8286270628
JACKIE ED14ARDS
PAGE 06
Form CS-SSQ
Collection System SanitarySewer Overffow Reporting Form
PART 1
TWO form shall be sUbmitted to the appropriate DWO Regional OMce in five
"sasof the tier knowlsdg!e of
nitary sewer overflow (SSO).
F'ermR Number: ,n
., Yead (WQCSft If advo, otha wi" use tneatuwd p1w Rfuma)
J
Fadtity - Incident#
Owner N e✓
• Ciky: ._. Repine: �
County.
Source of wo (chock appticsbre) : Serdtary Sewer Pump Station
SPECIFIC location offhe SSO (tie WwlaWt in description IMM past reports or docum n .1. Pump Solon 6,
Manhole at Westall tk Bragg Street. etc.) :
Latitude(ftmewwnulwisecond): 1.onglwda(degran rnimde►sscond)
{mom 1 TIM l�q' inddentInd D*
hh�— ,y
iYYY9) hrxrnln:AWPM
Esft2W volume of fl'he SSO: gallons Estimated Duration (Ro and to rmerest hau*
Describe how rho volume was determined:
Weallwoondittons during K I /
pid 354 reach surface ? es❑No Unknown Volume rewhing surface waaters (gagers):
Stufaca Water name:
Did the 5S0 result to s fah kit? ❑Yoe ❑ No 1 J Un `mmn If Yes, whet b the astimatad number of fish kpl®d�
SPECIFIC c��ts of the 550:
Le -SWAM Natural Candhion ❑ [scree 13
!fit¢
❑ Inflow and InStration ❑ Pimp Station EcOpmsnt Failure 0 Power outage
❑ Vandalism ❑ Debris In line ❑ Other (Please expita in fart il)
I mmed 24-hour verbal notification reported to: '�` 'r' _Gvr /tf.4r a� •
pWQ 0• Emergency Mpmt bate (rnmifd-WW): 1Tme (hh:mm AMJPM) �,
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped
Ask G.S.143-216.1C(b), the responsible party of a discharge of 1.000 gallons or of untreated wraogro aW to surface
waters shell Issue a pre release within 4a-hours of first knowledge to WI print and electrord4 pwm media providing Senervi
coverage In the curvy wire $die 'recharge occurred. When 16,WO gaAans or more of urmeatad waamwater enrars atbfaael
waters, a public notice shalt be published within 10 stays end proof of pvbll zWon shall be provided to the DNblon wiff in 3U days.
Refer to the referencad shUo forfurther deal
The Olracwr, ONIslon of Water Quality, may take enforoemazt salIM for SSCIs that are reoulred to to reported to Division unlass it
Is demonut ated jbpl;
f) the discharge was caused by severe natural condldons and there wore no faadble attemativas to the atecttargo: or
2) the discharge was exc optional, unintentional, temporary and caused by factors beyond the ressonabla eonbot of the Permitt e
mr4for owner. and the discivuge could not have been prevented by the exercise of roasorable control.
Pert 11 must be completed to pravide a )us; facstlon Balm for either of the alcove situaUcrs.'CWs Information will be file basis
for the dctermineUon of any enforcement action. Therefore. ft Is important to be as conplato so possible.
WHET"ER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
W,"C> Farm October g, 2W3 - Page 1
R
E E� VE
. D
S E P 2 4 2004 0
WATER QUALITY SECTION
ASHEV1LLE REGIONAL OFFICE

82BB270629
JACKIE ED14ARDS
PAGE 67
Form CS-SSO
Coilodon System Sanitary Sewer Overflow Reporting Form
PART I
This form shall be submitted to the appropriate DWQ Regional Office within fire daysof the first knowledge of
the sanitary sewer overflew (9SO),
Pew Meer: CO3 (WQCS# If adios. otherwlse use treatment plant NMC161)
Fadt y � � "`"� Inddwd #
Owner. a2 CILIA"Region:
air 046�1" M a gkwaz
Sw= of SSO (check aRkitt)fa) : Sanllary Sewer PO Pump Staiinn
SPECIFIC kxwffun of the 880 (be consistent in deaWpoon t reports or dote onration - i e. Pu n g,
Manhole at Westall & Mugg Street, at,
; X ' ,
Latitude (degnmslmtnufi%Awcond):
Al-a�gltude{d4preae/minutatsearnd}.
IndtlentStmdartl-17 oD`/ TimaS�'�r� InddentEndDi. L/7--0�
m rime
f�+*dd-YyM hhx AWPM f Yyyr} htrmm AWm
Estirnated values of the SSG:
Describe hour the volt" was determined:
Weather conditions during $SD event.--2
genera Estimated Duration (Round to nearest hwr);-
Did 5130 reach surface w.aitters?- Ili Yes L J Nov Unlmowm Volume r+eachlns surface waters {gallons):
$urFam water name: a.—
Did the SSd result in a fish kill? 13 Yes ❑ No 0 UnMorm If Yes. what Is time astimaled numbar of fish knied?
SPECIFIC �c,.a ) of the 880;
L Severe NaWrel Cone Non ❑Grease ❑Floats
El Inflow arid lrrfif vgm ❑ Pump Stadan Equipnwtl=allrrre ❑ PMW outvae
© Vandalism ❑ Debris in line ❑ CMher (Please expla9n In Part Iq
Inwrmedlats 244,iour verbal npwimllon reported to: - & '
�DVVQ El. Ernerpenry Mgmt. Date (rmrwdd-yjyy): oy Tim® mm
If an SSp to ongoing. please notify Regional Office on a daily basis until SSO can be stopped.
P-er 0.$. 143-215.1 C(b), time responsible party of a dischaof 1,000 gallons or more of untreated wastewater to surface
waters shall Issue a release rvtrge d8-hours of first kwwledge to all print and electronic news media providing pene�rel
coverage In the talrrrty�e ia�rsdrarge-oc curred. Whm 15.000 gallons or morn of uri aetad wastewater enteru surface
waters. a public notice arraA be published WMn 14 days and proof of publicstlon shall be provided to the DMsion mKtNiln 3D days.
Refer to the Merenoad statuta ferf Cher doted.
The Dlreclor. DMalon of Water Quality, a ff take enforcement action for SSA that are resulted to be mpartad to Divklon unlaces It
Is dmm2M±jted that
1) the discharge was caused by severe natural conditions and there were no fdasible attemadvas to the discharge; or
2) fhe discharge was exceptional, unintentional, temporary and moused byfactors beyond the reesonabla control of the Parmitteer
and/or owner. and the discharge could not have been prevented by the exercise of remonable control.
Part 11 must be completed to provide a JuStIfICation Bairn foretther of the above situations. This Information will be the basis
fcrthe determination of any enfmceriwnt action. Therefore, it is Important to be as complete as possible.
WHETHER OR NOT PART 11 IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
C."80 Form OdDbw 8, 2003
Page 7
® EcE�yC
S EP 2 4 2004
WATER QUALITY SECTION
ASHEVILLE REGIONAL OFFICE

01/08,12000 14:23 8286270620 JACKIE ED14APM PAGE 08
Ceflactlort System Sanbry Sawer()verflow Re Jm CS-SSQ
pOrUng Forth
This forrn shall be subrnttt$d to the eg -� PART 1
the Sark" sewer overflow (MO). appropriate DWQ R tonal t3ffiee within !2 dam Of the first I fyowledge of
Permit Number:tx�
(Mr.W If "cOwe3, otharwisa use treabnent plant NG1tJv( FscifJty +t l'
OWr Incident #
CI1y Region: Y
Source Of SSO (check sAAjk'jatrre) : 9� Sanitary Sewer
S LV4171C location of the Sao (be inns
Manhole at Weetal & aragg Sheet, eto
Latitude ('�iinuteJaecarrd);
Jncident Startled Dt: ��,f'� l�t — .I -AYJ�
("hh:mrn
Pulsated volume of the SSd; gafJprrtb
ao:XAba how the volume was determined:
Weather condltltma during S90 event -A
bid $SO reach surface 7 ©"T
NO � Unknown
Su►fu0e water name:—;-d�� ,i,� �,,�
Old the $5O result in a ffeth 1oiR7 yes [�Jrla Unkrmum
SPECIFIC of the Sm.
i9 Prenp Station
or �rw nerrtatlorr - f.e. Rump Station 0.
L'Ingltude(dograWmtnutt secow)
incident End Dr 1���'nP �f .� �t
(mn}dd-yyyy) hh.m AMrp►f
Estimated Duration (Round b nearest hour,); - .
volume reaching surface watota (gam): — —
if Yes,, "at is the namated r Jmt r of fish lalfred7
SGVere Nature[ Condition El Oman Q
0 Inflow and InflIb Lion ❑ Rao
-� PURrp Station Equlprneni i=allure EL]-� P iyow
C3 er ouPa�
Vandalism Debris In One
_ Q Ottrer (Pfears erplein In part ft)
Imrrt® to 24,hourverbel Y-Mcaaton reported to: i.,o O�Gc*
""C E3 mnemorw MBmL Osfemm.dd-
( �'y19'� ay TTrr►® (htxmm AMIPM)�
if en SSQ is ongoing, please notify Regional Qflke qry a daily basis unffl SSQ can 6e slapped.
G.S. t4:�21+5.iC(b), the raspansihle party ors discharger of f.DQt1 gallons a stare of uMtBatad
waters Sttstl tssue a m ours of fhat laratvl wesrnuE
ee to mliv s
mvemp Ih the county eta a s to sll print and u*02 rle newts maidir� $enerar
waterer, a Public ho ice ahr�ll be ptrblist d within 1d rr�dtit lions or scone of erntre�d vrsstawam aurfec e
Defer to the referenced atabrle for further rtetaA. A Pb [bile short be prrnRdsci 14 then wfthin 3D ley$,
The Olr for Division of Water Quslity. may take enforcement acdon for BE— list are rani to be re to Dlviahm unless it
a er
4) the discharge was caused by aevem natural wnditlons and them were no feasible altemnaves to the disdlzirge; or
2) th& dischrrge was exceptlonaf, unintentional. temporary and caused by factors bsyond the reasonable control of the Perrnfttabs
arx 1for owner. and the discharge eauld not have been prevented by the r:xardae of ramonable control. -
Part 11 must be conrpimted to provkfe 9 JurtMrZVon claim for aitherof the above 40MIC Ra. This inforrnadan wig be the basis
for the deteimination of arty enforcement action. Therefore, it Is important to be as campfete as po&Qbie.
WHETHER OR NOT PART II JS COMPLETED, A SIGNATURE 15 REQUIRED AT THE END OF THJS FORM-
0$tiWo Form Ootaher g. 2063
Page t
ECNVE
D FSP 2 4 2004 D
WATER QUALITY SECTION
ASHEVILLE REGInNAe ru:m •

01/08,12000 14:23 8286270628 JACKIE ED14APDS PAGE 09
&
Form GS-SS0
- collection System Sanitary Saar ()verllow Reporting Form
-- PART I
thee sanftBFry Omer overflow 7form shall be et to the aPProDnate D1NQ Ftegit Aid Ofte within fEsof the first kndwledga of
( {SSG).
Permit Number:
-" —�- 1Nt'C
Clwner: S# M adNe, othDiwise use treatrr�er�t plant NCJYIK7#j
y Incident g
Region:
+'� • 1
cur, -A -- ReiCounty:
Sourva of SSO (cheek applicable) : Sanitary Sever �`- Pump Station
SPECIFIC lacaUwr of the SW (be C=116tW In description fmm peat reDetteer u�►en tin - o. iyum�r St {oh 8.
Mantrole at WasW & Bragg Street, atc.):
Lad4ude (d��lminuterlse4and): —.
Incident Started Dt . !7--R</ Time,
(R+►n dd ririyy) hh:rrnM
Estimated volume of the S$O: -- gallons
Dascri6a how the volume WAS CWOMti ied:
Wsathw conditions during SSO snren"
Did SSO reach maface, waters? �YesLJNJ i tlnkr m
Surface water narn®: �aal ,,.�,./�
Did the SSO rasutt Ina fish kW ❑ YOS❑ N-J3 Unkrrowrr
SPECIFIC cam OJI of the SSo:
5ovara Natural Condition
❑ irrfionrand InfMmWn
13 VWXMISm
Immediate 24-hour vat notification reported W
z nwo ❑ ant-Y
L0n9hude(d89roeshn1nuWsecond)
Incident E..nd
(r""&yM) hkmm AMNIA
Emirnated Durawn (ftund to newest hour)r-.
Volume teaching surface water& (gult"):
If YWB What Is the estimated number of fish I4p6d? „_
® Grow. ❑ Roots
❑ Pl#rrp Station Equipment F;alture ❑ poww Gulags
© Debris In Eno ❑ Other (Phrase explain In Part 11)
Tim { &-rn AM/Pfut?rL�L_ICJI �J
If an SSO is ongoing, please notify Regional Office on a dally basis until SSO can be stopped.
Fra G.S. 1A3-215.10(b), the responsible pa of a disoija e, of i.0W galona or more or untreated wastowot r to surface
waters shall issue a remiss release within48-houts of first ImouAadBe to all print and electronic new$ media providing general
coverage In the o3wily 9-m d herga omurmd. When 15.000 gallons or moos of unheated wastewater eaten eurrrum
waters, a public notice shall be published within 10 days and proof of publication shut be provided to the Division within 30 days.
Refer to the ref ffwt;W statute for further detail.
The Dlreryr, Division of water Quality, may take errfarr emerrt action for Saos that am qMkpd tD be reported to Divides unless tt
1) the diadwrge was caused by severo naturst conditions and there were no feasibla alternatives to the discharge,; or
2) the discharge was exceptional. uninfordlonai, tenrpors►y and caused by factors be+yorrd the rem onabie control of the Pemdttea
and/or owner, and the discharge could trot have been prevented tsy the exercise of raasoname Wntrol.
Part 11 tntW be completed to provide a justification claim for elttier of the above situations. This inromWJon will be the bash
for the determination of any embrcement action. Thomfore, It is Important to be as complete as possible.
WHETHER OR NOT FART Il 1S COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form 0ctobar9.2ou3 page 5
SEP 2 4 2004 DO
WATER QUALITY SECTION
ASHEVILLE REGIONAL OFFICE

01I08,12000 14: 23 82862 i 0628 JACKIE ED14AP.DS PAGE 10
Form CS-SSO
_ Collection System Sarlltaiy Sewer Overflow Reporang Form
-- PART I I
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN FART I OF THIS FORM
AND INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIRED OR MIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN PART I
In ft chock boxes below, NA = Not Applicable and NE = Not Evaluated
A HARDCOPY OF T1418 FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWO REGIONAL OFFteE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THIr ONLINE REPORTINo SYSTEM
Soya ? Natural Condition hurricane tornado etc.
Desrsibe the'savet;e nattcrdl obnddfpn' In detail.
How much advance warning dId you have and what awons were taken In
etc. should be available upon request./
when WHO the last time this spedtic fine (or wet welt} was Cleaned?
the evantl
7d �+,lyt'yi e- r
P7�f�I6
Do YOU have an enforcaaple grease ordinance that requires new or retrofft of grease trapsimteptnrs7 ❑Yeti No EKA 0NE
HBVa there been r6bent inspections and/or eMorsament actions telto on nearby testauranls or other �Y� NONA ONE
nonresidential grease cantributocs7
Haves there been other SSOe or blockages in this area that years also caused by grease? Uyestj P NA pE
When?
tf ye% descilbe thern:
Have cleaning and inspections ever 4wn increased at this location? Yes No MIA NE
Explalm
CS-SSO Form October 9, 20V3 Page 2

01/03,12000 14:23 92BB2 OG28 JAa<IE ED14AP.DS PAGE 11
Nave eduC&tional matarlals about grease been distributed In the pest?
WhOA7
and to whom?
11Ye10 NIONgOkE
Explain?
If tea $SO occurred at a pump atatlon, when was the wet well and pumps had checked for grease
accumulation? —
Wera th4 floats dawn? ❑Y..O 1, a F ONe
Canmeme:
Roots
Do you have an add* root control program? OYMO No 0NA ONE
DowAbe
Nave cleaning and inspecOon8 aver been ino eased at this Ineation because at rootg7 YeaLJ Nb NA NE T
Explain:
What cOr@tllve arttpne have been accompilshed at the SSO kxation (and surrounding system If
406Wated vWth the SSO)?
What corrective aO JOhs are planned at the SSO location to reduce root hin lslon?
Has the Ins been smoke tested or vtdeoed vAthfn the past year? Yset...3 Na NA NE
If Yes, when?
Comments:
Inflow and Infiltration
Are ynu undor an BOO (Speolal Omer by Consent) or do you have a schadde In any permit that tuY.] w-XC FINE Utz
CS-SSo (=ann O=bL-r'a, 2003 Page 3

01/08,12000 14:23 82BB270828 JACKIE EDWAP.DS PAGE 12
Explain I Yes:
What cx rrectIve actions have been taken tv uKUCa or eliminate I & I related overflows at this spill ivcation
within the last year?
Has dwra been any flow studies to determine !A problams in the collection system at the SSO IaaCatibn? DYWO N4DNA CINE
If Yes, when was they amdy Completed and what actions did it recommend?
Has the Gnu been emme testod or videaed within the past year? Y�
if Yes, when aril Indicate what Actions aro necessary and the status of such ectlons:
Am them 111 roww "am in yourCapitai Improvement plen7 Ye0 tJn NA NE
tf Yes, explain:
Have thum been any grant or loan applications for Ill reduction projects? 11y—X Na NA NP
K Yes, explain. -
Do you Sumpect any msjor soUrr.03 of intlOw or cross connections with stmm,s rs? �Y No NA NE
If Yes, explain:
Have ail lines contacting surface waters in the SSO 100aWn and upstream been inspected recently? ©YGE Na NA ❑NE
If Yes, explain:
What other oorrachlre actions are planned to prevent future Vi related SSOs at this location?
comments:
Pump Station Equipment Failure Documentation of tssting, records etc.,
shout be provident upon request.)
What kind of r-Mationfalarm systems are present?
Auto-dialerAdemQtry (one-way CommunicaWn)
r.._IYes
CS-SSO Form October 9, 2003 — Page 4

01I08;2000 14:23 8286270628 JACKIE ED14ARDS PAGE 13
Audible
Visual
SCADA (two-way communicatbri)
Emergency Contact Signage
Other
0(es
OY6s
OYss
Dres
Ely .
Describe the equipmentthatfailed?
What kind of situations trigger an alarm oongitton at this station (i.e. pump Mum, power failure, high
water, etc.)?
Were noWcatior"larm systems operable? Ll Ye,U No NA NE
If W. explain:
If a ?lump failed, when was the last maintenance and?ar Inspedipp performed?
Whet specifically was CNCkedfmaintained?
If a valve farad, whan was it last exercjsW? +/
Were an pumps set to altematV ❑YX No O NA ONE
Did any pump show above normal run times prior to and during the SW event? DY.10 N, E Nh ❑NE
Were adequate spare parts an hand to fits the equipment (swkh, fuse, valve, seal. etc.)? LRy.0 N42il D NE
Was a eparD or portable pump Immediately avallable? t ywO NoUNAt.INP
If a float problem, whan ware the floats last tested? How?
If an auto -dialer or SCADA, when was the system last tested? Hamel
Comments:
CS-SSO Form Octobar R. 2D03
Page 6

01/08,12000 14:23 8286270628 JACKIE ED14ARDS PAGE 14
Power outage (Documentation of twtincl, records, etc., should be
provided of altemathre power source upon request.)
What Is your ariemete pourer or pumper source?
Did it function propW
Des021e4
When was the alternate power br pumping sc+l ww I= tested under bad?
If eauaed by a wasther event, trove mud{ advance waming did you have and what actinns were tatkan to
prepare forOm evem?
Comments:
Vandalism
Pruwde ponce report number.
Was the site secured? 13Y�J ftEKiA©r&
If Y how?
Pa'loa d Control Panel
Have there been previous problems with vandalism at the SSo location? Ye�LJ hf MA NE
If Yes, explain:
What samrity measures have been put In puce to prevent similar occurrences in the fh tury DYE Mo nta � NE
Debris In line Rocks sticks ra s and other items not allowed in the
collection system, etc.)
Whet type of debris has been found in the fine?
How muId it have gotten Owe?
Am manholes in the area Secure and inter? UY.Aj WVJXAUNE
CS-SSO Farm Woher 9, 2D03 Page e

01/88/2000 14:23 82B6270628 JACKIE ED14AP.DS PAGE 15
When was the area test checkeftleaned?
Have cleaning and inspectlons ever been Inc&mad atthJstocabon due to previous pmblems with debrw 13YeO N4�NA QNE
Explain:
Are approprkdo educational materials being developed and dlsWbuted to preml future similar IJYesO NgrL_INA CINE
occurrences?
Comments:
Other (Pictures and a police report shouid he available upon request.
Describe:
Wets adequate equipment and resources available tD fix the problem? tJtY60 NOOMADNE
If Yes. explain:
If the problem could root be immediately repalred, what actions were taken to Wsen the Impact of the
SSG?
tJommerr:
For DWd Use Onl .
DWp Requested an Addttion$I Written ROW; 11YB,C] NoEINA LINE
If Yes, What Act tional information Is Needed-,
Cranm�ts:
CS-SSO Form October 3, 2oo3 Page 7

r
01/08,12000_14:23 8286270628 JACKIE EDWAP.DS PAGE 16
As a representattya for the responsible party, l certify that tha information contained in this report Is true and accurate
to the best of my knowledge.
Parson .9ubmittin9 claim:
Signature:
� •--- Tide: &443L
TetBptr4ng Number. d
Any addidonaf Information desired to be submitted ahmAd be sent to the apprnprlate bivi$ion Regional Office wittyfn tine day% of first
knowledge of the 880 Wfth reference to the Incident number (tlia incident number Is only generated when waeo orac entry of tide form
I$ Completed, if used).
C5•SSO Form Qctober 9. 20c a

�j SEP 3 0 2004
51 D _ r WATER QUALITY
-�; Collection SyStern R HEVILLE REEGI�`Ot
This form shall be submitted to the approp$iate DWq Regional Office iWthln five days of the first knowledge of
the ,sanitarysewer ovedow (SSO). ..
1g Fort
PART i
Permit !Number G�J ��
—7- UGS# If active, otherwise use treatment plant NCIWQa)
tJwnar • Incident #
City:
Region: r� t
County:
Source of SSO (check applicable) : Sanitary Sewer ❑ Punv Station
SPECIFIC bcatlart of this SSO (be consistent in d cription !rom past repots or documentation - Le. Ptanp Station g,
Manhole at Westati & Bragg Street, etc.)
Latitude (degreeslminu(ehec ond): Lon9itude(daWaa&%Iinute/second)-
Incidont Started D Titre- Q.� • ff, incktent F�td DL Ap"er'� eci
(+► YYYY) tA►:nvriRty{IPM (rnmcid nt E Time-
d d t>h-" AMIPM
Estimated voturne of the SSO: gallons Eslimafe(f Duration (Round to nearest hour):• Z bf 6j
Doscriba how the volume was dolam9nod: o
Weather condillons during SSO event:
Did SSa road suffacv waters? OYos ONO ❑ Unknown Vetumo teaching surface tvatera (gallons):
Surface water name: urn - ,—
Did the SSQ• result in a fish khl7 ❑ Yes RM 0 Unknown if Yes, what Is the estimated number of fish killed?--- -
SPECIFIC CBUWV,) of the SSG:
Severe Natural Condition ❑ Grease ❑ Roofs
❑ Inflow and Infiltration ❑ Pump Station Equipment Failure ❑ Powor outage
❑ Vandalism ❑ Debits in lino ❑ Other (Please explain (n Part IQ
Immediate 24-hour varbat nolitication reported to: K
DWO 0 Emergency Mgt, Date (mm-dd-yyyy): C�_,7►�—py Time (hhanm AMIPM): ?:C/S- Act
If an SSO Is ongoing, please notify Regional Office on a daily basis until $SO can he stopped.
Per G.S. 143-215.1C(b), the responsible party of a discharge of 1.000 gallons or more of unfrosted wastewater to surface
waters shil" issue at press release within 484roura of first knowledge to all print and electfortic news media providing general
coverage in the oauttty rs t recharge occurred. When 15.000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be pWished wilhln 10 days and proof of publication shall be provided W the Division within 30 days,
Refer to the referenced aujute for further defall.
The Director, Division of Water Quality, may take onfcucemont.action for SSOr. that are reg"i ed to be reported to Division unless it
(IP-clerntxtrtrafad that;
1) the discharge was caused by severe natural conditions and there ware no feasible aitematives to the discharge; or
2) the discharge was exceptional. Unintentional, temporary and caused by factors beyond the reasonable cwttrot Of the permlttee
andlor owner. and the discharge could not have been prevented by the exercise of reasonobte controL
Part II must be completed to provide a justi ication claim for either of (he above situatlons. Ibis Information will be the basis
for the determination of any enforcement action. Theretore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLEYEC1, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
US-Sso Form October 9, 2003 p 1

U E I V E Form CS-SSO
-1 ColFFSEP
m Sanitary S e verflow Reporting Form
2 7 2004
` Il� PART I
This form shall be submitted to the appropriate DWQ Reg r
nal a—+ntil f th first knowledge of
the sanitary sewer overflow (SSO). WATER kttT SMY
ASHEVILLE REGIONAL OFFICE
Permit Number: N60025`193 %T (WQCS# if active, otherwise use treatment plant NCNMQ#)
Facility:
Owner:/'C✓f�D Gl/�=TirUi'G�
city: .4/k Alc .2 960:'
Incident #
Region:
County:!/�✓'y
Source of SSO (check applicable) : Sanitary Sewer 0 Pump Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation - i.e. Pump Station 6,
Manhole at Westall & Bragg Street, etc.) :
Latitude (degrees/minute/second):
Incident Started Dt: Time: •10O
(mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: Q ocn0 gallons
Longitude(degrees/minute/second)•
Incident End Dt:. Time- 16-oy
(mm-dd-yyyy) hh:mm AM/PM
Estimated Duration (Round to nearest hour): `4.14
Describe how the volume was determined: Weather conditions during SSO event: �Z; 4 c' J 4P PI-OA2 11a'-" 'i CC7z2C
Did SSO reach surface waters? 0 es No Unknown Volume reaching surface waters (gallons):
Surface water name: �/7x-
Did the SSO result in a fish kill? El Yes WINo Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
XSevere Natural Condition ❑ Grease El Roots
El Inflow and Infiltration EJ Pump Station Equipment Failure EJ Power outage
El Vandalism ❑ Debris in line ❑ Other (Please explain in Part II)
Immediate 24-hour verbal notification reported to:
DWQ E] Emergency Mgmt. Date (mm-dd=yyyy): ,�vz1 Time (hh:mm AM/PM): 9DUfVso7
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003 Page 1

For
yCollection System Sanitary Sewer Overflow Reporti
ANSWER THE FOLLOWING; QUESTIONS FOR EACH .RELATED CAUSE CHECKED IN PART I OF THIS FGrvvi
AND INCLUDE THE APPROPRIATE.DOCUMENTATION.AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN.PART I
In the check boxes below, NA = Not Applicable and NE = Not Evaluated
A HARDCOPY OF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWQ REGIONAL OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Severe Natural Condition (hurricane. tornado. etc.
Describe the "severe natural condition" in detail.
9!
How much advance warning did you have and what actions were taken in preparation for the event?
Comments:
Grease (Documentation such as cleaning, inspections, enforcement
actions, past overflow reports, educational material and' distribution date,
etc. should be available upon request.)
When was the last time this specific line (or wet well) was cleaned?
Do you have an enforceable grease ordinance that requires new or retrofit of grease traps/interceptors?
Have there been recent inspections and/or enforcement actions taken on nearby restaurants or other
nonresidential grease contributors?
Explain.
❑Yes❑ No❑NA❑NE
❑Yes❑ No DNA ONE
Have there been other SSOs or blockages in this area that were also caused by grease? ❑Yes❑ No ❑ NA ❑NE
When?
If yes, describe them:
Have cleaning and inspections ever been increased at this location? ❑Yes❑ No ❑NA❑NE
Explain.
CS-SSO Form October 9, 2003 Page 2

als about grease been distributed in the past?
and to whom?
Explain?
❑Yes❑ No ❑NA ❑NE
If the SSO occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation?
Were the floats clean? ❑Yes❑ No ❑NA ❑NE
Comments:
Roots
Do you have an active root control program?
❑ Yes❑ No ❑ NA ❑ NE
Describe
Have cleaning and inspections ever been increased at this location because of roots? ❑Yes❑ No ❑NA ❑NE
Explain:
What corrective actions have been accomplished at the SSO location (and surrounding system if
associated with the SSO)?
What corrective actions are planned at the SSO location to reduce root intrusion?
Has the line been smoke tested or videoed within the past year? ❑Yes❑ No ❑NA ❑ NE
If Yes, when?
Comments:
Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule in any permit that ❑Yes❑ No ❑NA ❑NE
addresses 1/1?
CS-SSO Form October 9, 2003 Page 3

Explain if Yes:
What corrective actions have been taken to reduce or eliminate I & I related overflows at this spill location
within the last year?
Has there been any flow studies to determine 1/1 problems in the collection system at the SSO location? ❑YesMNo ❑NA ❑NE
If Yes, when was the study completed and what actions did it recommend?
Has the line been smoke tested or videoed within the past year? ❑Yes❑ No ❑ NA ❑ NE
If Yes, when and indicate what actions are necessary and the status of such actions:
Are there 1/1 related projects in your Capital Improvement Plan? ❑YeSI'Mi No ❑NA ❑NE
If Yes, explain:
Have there been any grant or loan applications for 1/1 reduction projects? ❑YesM No ❑NA ❑NE
If Yes, explain:
Do you suspect any major sources of inflow or cross connections with storm sewers? ❑YesN" No DNA ❑NE
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream been inspected recently? ❑Yes❑ No❑NA❑NE
If Yes, explain:
What other corrective actions are planned to prevent future 1/1 related SSOs at this location?
Comments:
Pump Station Equipment Failure (Documentation of testing, records etc.,
shoul be provided upon request.)
What kind of notification/alarm systems are present?
Auto-dialer/telemetry (one-way communication)
❑ Yes
CS-SSO Form October 9, 2003 Page 4

SCADA (two-way communication)
Emergency Contact Signage
Other
❑ Yes
❑ Yes
❑ Yes
❑ Yes
❑ Yes
Describe the equipment that failed?
What kind of situations trigger an alarm condition at this station (i.e. pump failure, power failure, high
water, etc.)?
Were notification/alarm systems operable? ,Ryes❑ No ❑ NA ❑ NE
If no, explain:
If a pump failed, when was the last maintenance and/or inspection performed?
What specifically was checked/maintained?
If a valve failed, when was it last exercised?
Were all pumps set to alternate?
Did any pump show above normal run times prior to and during the SSO event?
Were adequate spare parts on hand to fix the equipment (switch, fuse, valve, seal, etc.)?
Was a spare or portable pump immediately available?
If a float problem, when were the floats last tested? How?
If an auto -dialer or SCADA, when was the system last tested? How?
Comments:
❑Yes❑ No ❑ NA ❑ NE
❑ Yes❑ No ❑ NA ❑ NE
❑Yes❑ No DNA ❑NE
❑Yes❑ No❑NA❑NE
CS-SSO Form October 9, 2003
Page 5

Power outage (Documentation of testing, records, etc., should be
provided of alternative power source upon request.)
What is your alternate power or pumping source?
Did it function properly?
Describe?
When was the alternate power or pumping source last tested under load?
If caused by a weather event, how much advance warning did you have and what actions were taken to
prepare for the event?
Comments:
Vandalism
Provide police report number:
Was the site secured?
If Yes, how?
❑ YesU No t-1 NA U NE
❑YesO NoElNAElNE
Have there been previous problems with vandalism at the SSO location? ❑Yes[] No 0 NA ❑ NE
If Yes, explain:
What security measures have been put in place to prevent similar occurrences in the future? ❑YesO No ❑NA ONE
Comments:
Debris in line (Rocks, sticks, rags and other items not allowed in the
collection system, etc.
What type of debris has been found in the line?
How could it have gotten there?
Are manholes in the area secure and intact? DYesO No DNA ❑NE
CS-SSO Form October 9, 2003 Page 6

hecked/cleaned?
;tions ever been increased at this location due to previous problems with debris? ❑Yes❑ No ❑ NA ONE
Explain:
Are appropriate educational materials being developed and distributed to prevent future similar
occurrences?
Comments:
Other (Pictures and a police report should be available upon request.
Describe:
❑ Yes❑ No ❑ NA ❑ N E
Were adequate equipment and resources available to fix the problem? ❑Yes❑ No ❑NA ❑NE
If Yes, explain:
If the problem could not be immediately repaired, what actions were taken to lessen the impact of the
SSO?
Comments:
For DWQ Use Only:
DWQ Requested an Additional Written Report:
If Yes, What Additional Information is Needed:
Comments:
❑Yes❑ No❑NA❑NE
CS-SSO Form October 9, 2003 Page 7

As a representative for the res
to the best of my knowledge.
Person submitting claim:
ble party, I certify that the information contained in this report is true and ac'M
Signature: A&
Date: 9/a / �
Title:��q
Telephone Number:
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five days of first
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of this form
is completed, if used).
CS-SSO Form October 9, 2003 Page 8

07:11 02B-733-1918
LAMD HARBOR
C411%tion System
D) V E
F-SCTP72iD
iD0 2004
WA
This form shall be submitted to the appropriate DWQ Reg anal Office within rive dM of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number: >j,'Z'�§` �%s
QV QCS9 if active, athem4sa use treatment plant NC/WCW)
Faclity ++ Incident #
Region_
Cbv
Source of SSG (check applicable) ; � Sanitary Sewer
SPECIFIC facation of the SSO (be consWent in des 'pti¢r3 fro
Manure at WestaR & /Brragg streee�t,yyew)i : `
B t . ('Ii7D ia•`zr '� • M
Latitude (degrees/min'uWAecond);
nty_
xhump Station .
past reporrt� or`dgeumenntta� -or, i.e. 7P)"Ip Ststipn 0.
�rs.,t yf.i•ae._ �4d... tlL�i,.tlt
Mdent Started Dt: - 'rime. /40. 1944i.
(mm-dd-'1YYI/) hh mm ANWM
);Wfnated volume of the SSO; gallons
rJ�O -- fro.
DegWbe ]tow the volume was determined: 4- �f
Weather conditions during SSO event:
Did SSO reach surface water - )PP; ❑ No 0 Unknown
Surface webw name:
Did the $SO result in a fish kill's' © Yes m o El Unknown
SPECIFIC car.rsu(s) of the SSO:
OkSevere Natural Canditinn
Q Inflow and Infiltration
El Vandalism
Immi,bOiato 24-hourverh9l notifk:ation reported to:
DWQ = Emergency Mgmt
Lon dud g' e(d egrees/mtnutelsecond)• � 13 �
Incident End Dt 1? E7
(mm•dd-YYyy) hhmm AMMM
alimated Duration L _Round to neatest how):—'16
.r -r.+-p
Volume reaching surtac:e•waters (gallons):
It Yes, ghat is the estimated number of fish fulled
?-
Q raFaaSe El Rdals
0 Pump Station Equipment FWlure El Pmmr outage
Debris in line 0 Other (Please explain in Part 11)
4mll 4"11
lime (htt:mm AIWPM):i �ss?/►
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Date (rnm-dd-yyyy):
Per G.S. 14:-2-irmc(b), the rcmponsf3le party of a discharge of 1,000 gallons of more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media pmviding general
coverage In the County where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shell be published within 40.days and proof of publication shall be provided to the DWIsion within 30 days.
Refer to the referenced statute for further detail,
The Director, DMaion of Water Quality, may taste enforcement action for SSOs that are rleg iraounless t ed to be vorted to Division 4Is demonstrated that _.. , _ _ _ _ _
1) the discharge was caused by severe natural conditions and there wwo no feasible allematives to the discharge; or
2) the discharge vvas exceptional, unintentJonal, temporary and caused by factors beyond the reasonable control of the PermMee
and/or owner, end the dischorge could trot have been prevented by the exerc;ec of reasonable control.
Park 11 must be completed to provide a justification claim for either of the above situations. This information will be the basis
far the determination of anyenforcernent action. Titerefom, it is important to be as COMplete as possible.
WHETHER OR NOT PART If IS COMPLETED, A SIGNATURS IS REQUIRED AT THE FzNb OF THIS FORM.
CS-SSO Form October 9, 2003 Page l

07: 11
828-733-1918
LAND HARBOR PDA
PAGE 63
Form CS-SSO
COIJOC On System Sanitary Sewer Overflow Reporting Form
-- FART I I
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN PART 1 OF THIS FORM
AND INCLUDE THE ?APPROPRIATE DOCUMENTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING TO THE CAUSE OF T1iE SSQ AS CHECKED IN PART I
In the check.boxen below, NA:-- Not Applicable and NE = Not ?Evaluated
A HARDCOPY OF THIS,FORM SHOULD BE SUBMITTED To THE APPROPRIATE DWQ REGIONAL, OFFICE
UNLESS IT HAS BEEN SUBMITTED M ECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Severe Natural Condition hurricane tornado etc.
DeWAI3e the "seVere natural conrlliion" in detail.
iY4sr�+��ir�•��As.., -� �� ti Yti!)e. �� R /�Jw►s4r SRJ7�'�� �Ar+M+- �l+�tyT..#-��...
how much advanc6 waming did mw
a have and what at%ans were taken in prepnralion for the event?
Grease
available
When was the last time this sperft line (or wet well) wa* cleaned?
Do you have an enfonmable grease ordkTanm that mquires new or ruh unt of grease trapslintierceplorO
Have there boon rcccnt inspetoons and/or enforcement actions taken on nearby rasiaurants or other
nanresirlenlial crease contributors?
Explain.
1—tY No
ONA❑NE
ElYW7 N.EINA ONE
Have there been other SSOs or blockages in this area that were alw caused by gmass? OY410 No ONA r INE
When?
If yes, deeWbe them:
Have caning and Inspections ever been Increased at this laeggon? ©y z Alb 0 N A ML
Explain.
CS-SSO Farm October % 2003
Page 2

09/23,12004 07:11 828-733-191B LAMM HARBOR PDA PAGE 04
Explain if Yes:
Whet corrective, actions have been taken to reduce or eliminate I & l related overiiows at this spot 10=40n
within the last year?
Has there been ony fowstfidles to determine III problems in the collection system at the•SSO location? Elysst._J No ❑NALINE
ftYes, when was the study compreWd and what actions did it recommend?
HaS the line been smake tested or videoed Wthin the past year? OYeasi -f No
if Yes, when and iJ,dipte what actions are necessary and the status of such actions:
Are there Vt related projects in your Capital improvement plan? ❑YMO tan !-114A EINE
It Yes, explain..
Have thWe been enY grant or loan applications for Ili reduction pmjects2 ClY--O No CINA ❑ NE
If Yes, explain;
Da you suspect any major souress of Inflow or cross connections with sbortn sewers? ❑YIET N L INA ©NE
IfYas, explain:
Have all I"enes contaoting surface waters in the SSO location and upstream been Inspected recently? 12Yes0No CINA IDNE
If Yes, explain:
What other corrective actions are planned to prevent future N related $30s at ;his kJcatlon?
Comments:
Pun • Station Equipment Failure Mocumentetion of testing, records etc_
shout he provided upon request)
What kind of noWtcation/alarm systems are present?
Auto-diaierAetemetry (one-way communication) ElYe s
CS-SS0 >=oon October 9, 2DO3 Page 4

9/23,12004 07:11 828-733-1918
LAND HARBOR PDA
PAGE 05
Have educational materials aboutgrease been dlstr'buted in the past? OYeO No ONA ONE
When?
and to wham?
Explaiti?
If the $50 occurred at a pump ststion, when was the wet Well and pumps last checked for griagse
accumulation? Were the floats clean? nYeGO No O NA ❑NE
Comments: .
Do you have an acUive root cantroi progtam?
0
QYes0 NQ ONAONI=
Describe
Have cleaning and Inspections ever been increased at VUs loomt9on because of robis? OYe.0 Na DNA ONE
F�cpta;n .
What coaWlve aetlons have been accarmpiished at the SSO location (and surrounding systlwm if
associated with the 530)7
What correcOve acBons are planned at the SSO locatfan to reduce root intrusion?
Has tip fine been smoke tested of videoed within the pest year? OYesO No ONA•ONE
If Yes, whan7
Comments:
Inflow and )nfiltmfion
Ail& you under an SOC (Speckd Order by Consent) or do you have a schedufe h any permit that ❑Y il+to�j1—[Nq L-INE
addresses IA?
CS-SSD i=orm . October 9, 2003 Page 3

34 87:11 028-733-1418
LAND HARBOR P❑A
Audible CjYes
Visual UYe
SCADA (tnra-way communication) 0Yas
Emergertcy Contact Signage ©yam
Cthbr Ely.
Desorbe•the equipment that fa,7ed?
What Idnd of situations trigger an alarm condi5on at this station (i.e. pump failure, power failure, high
wader, etc.)? r�
Were notiticatiWalann systems operable? 0Yadj 7 N. ©NAB ONE
If no, explain:
If a pump failed, when was the last maintenance andfor inspection performed?
What speedically was checkedlmeintelned7
PAGE 96
if a valve failed, when was it last exercised?
Were all pumps set is alternate?'
Did any pump show above normal run times prier to and during the SSO event?
Were adequate spare parts on hand fo fix the equipment (switch, fuse, valve, sear, etc.)7 '
ElYe-O NO IDNA ❑NS
DYe10 Noi...JNA�rQTTNE
❑Ye'l Pro �NAIINE
Was a spare or portable pump immediately available? ©Y i,,O Na CIMA ❑W
If a float problem, when were the floats last tested? Homy?
If an auto -dialer cr SCAADA, when was the system last tested? How*7
Comments_
CS-SSO 5orm October9: 200 page 5_

09/23,12004 07:11 828-733-191B LAND HARBOR PDA PAGE 07
Power Data a Documentation of testing, records etc, should be
royided of altemative power source _upon request,
What Es your alternate povver or purring source?
Qici 1x function properly? �fYesQ No OM ❑NE
>�esCribe7
When was the eftemate power or pumping source last tested under rand?
If caused by a weather event, hew much gdvance warning did you have and what actions were talon to
prepare Tor fie avant?
Comments:
Vandalism
Provide Police repart number. �
Was the. Site Secured?
QY1-0 Na QNA QNE
If Yes, how?
Have there been previous probleM with vandalism at the SSO location? CJY.0 No L1NA-0W
If Yin, explain' -
Mint Security measures have been put in place to prevent similar occurrences In fhe future? DYMO No ❑NA Q NE
Cnmmur ;
Debris in line (Rocks, sticks, rags and other items not allowed in the
collection system, etc.)
What type of debris has been found in the line?
How corlld it have gotten there?
Are manholes in the area secure and lnfact? OY050 No DNA ONE
CS' -.Sao Form- CkAober 9, 2003 paw .15

34 07:11 82B-733-1918 LAND HARBOR PDA PAGE 08
fhe area fast tieckedkiesned? f
Have cleaning and inspections ever been Increased at this kxa ion due to previous problems with debris? 'r-1Yes0 No ❑ NA ❑SIB
Explain:
Are appropriate educational maloriais Wing developed and dWbuted' to prevurlkfuture similar ❑YeO No ONAONE
occurrences?
Comments -
Other Pictures and a police rep2rt should be eyellable upon request-
liescribe:
Were adegaste equipment and resources available to fix the problem? ElYaSO NOONA ❑NE
If Yes, explain:
If fhe problem could not be irnmediak0yr repaired, what actions were takdn to lessen the Impact of the
550?
Commentm
For QWQ Use Oniy: `
DWQ-ReguesW an Additional Written Report 0YeoNc EINA DNE
If Yes, WhstAddHiortai Infonrration is Needed:
Comments:
C$-SSO Farm October % 2003
Page T

09/23/2004 07:11 82B-733-191B LAND HARBOR P❑A PAGE 09
As a represen#alive for the r>r. ponsil?Ie parxy, I caggy that the infommfjon contained in this report is true and accurate
to We best of my knowMge_
Person submitking claim}:
Signature.
Trde:
Telephone Number.,
Any addidowl Information desired to be submitted -should he sent to the appropriaie MAsion Regional Office within rive days of first
knowledge of the SSO In M reference to the incident number (the incident number is only generated when electronic entry of this form
is completed, if used).
j/ A�7
CS-SSO V mt October9, 2003 Page. 8

34 87:11 828-733-1918 LAND HARBOR P❑A PAGE 16
Notice of Discharge of Untreated Sewage
The Linville Land Harbor property Owners Association had a discharge of sewage
from our wastewater treatment plant, pump station and sewer main located at
180 Overlook Road of approximately 15,000 gallons. The discharge was first
discovered on September 16, 2004 at 10:00 p.m. -and lasted for approximately 96
hours. The untreated wastewater entered the Linville River of the Catawba Piver
basin. The treatment plant, pump station, and sewer main were repaired and back
in operation by 4:00 p.m. on September 20, 2004. This notice was required by
North Carolina General Statutes Article 21 Chapter 143.2.1 S.C.

u is ad" a idly sewer overrlow �JJ V ).
Permit Number: (,6019;17 6& (WQCS# if active, otherwise use treatment plant NC/WQ#)
Facility: (.Nil e, Law1 g�� & ' Incident # - ll
Owner: budit, 6 Aw6y 1 o,4, S'rsG • �5NG✓� i ,e
`c Region:
City: N*: ea�a,N'(�' County:
Source of SSO (check applicable) : Sanitary Sewer
SPECIFIC location of the SSO (be consistent
XPump Station
past
Manhole at Westall & Bragg Street, etc.)
011
Latitude (degrees/minute/tecond): ,w-0PAZ I
Incident Started Dt: 9114PD4 Time200,00,0?*N-
(mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: gallons
/40
Describe how the volume was determined: tXRd.#.
Weather conditions during SSO event:
Did SSO reach surface waters?/ 2Y s 0 No Unknown
Surface water name: �K✓.�1� ^'V`�'
Did the SSO result in a fish kill? ❑ Yes 52 No 0 Unknown
SPECIFIC rc�auusse(s) of the SSO:
L-w Severe Natural Condition
El Inflow and infiltration
El Vandalism
lmme 'ate 24-hour verbal notification reported to:
7DWQ = Emergency Mgmt.
- i.e. Pump Station 6,
Longitude(degrees/minute/second)•-$r Q 15
Incident End Dt: 9 0 Time•
(mm-dd-yyyy) hh:mm AM/PM
Estimated Duration Round to nearest hour):
Volume reaching surface waters (gallons): �d"
If Yes, what is the estimated number of fish killed?
11 Grease
El Pump Station Equipment Failure
El Debris in line
Roots
El Power outage
0 Other (Please explain in Part II)
Time (hh:mm AM/PM): Jr.' �5� 01-1
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Date (mm-dd-yyyy):
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003
Page 1

Form CS=SSO
Collection System Sanitary Sewer Overflow Reporting Form
PART I I
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN PART I OF THIS FORM
AND INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN PART I
In the check.boxe;3 below, NA = Not Applicable and NE = Not Evaluated
A HARDCOPY OF THIS -FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWQ REGIONAL OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Severe Natural Condition (hurricane, tornado, etc.
Describe the "severe natural condition" in detail.
�u�����ar�. - /� f r�.k�.�.Ll Crer,�Cs !i`y1��,9ro�+s�Saf��.N`re✓ �i�mzsa
How much advance warning did y u have and what actions were taken in preparation for the event?
�•s- ! let, was /.-91wt a/
l � 011AX 4 � 00,W4 l
Grease (Documentation such as cleaning, inspections, enforcement
actions, past overflow reports, educational material and distribution date,
etc. should be. available upon request.)
When was the last time this specific line (or wet well) was cleaned?
Do you have an enforceable grease ordinance that requires new or retrofit of grease traps/interceptors? ❑Yes❑' No.❑NA ❑NE
Have there been recent inspections and/or enforcement actions taken on nearby restaurants or other ❑Yes❑ No ❑NA ONE
nonresidential grease contributors?
Explain. -
Have there been other SSOs or blockages in this area that were also- caused by grease? ❑Yes❑ No ❑ NA ❑ NE
When?
If yes, describe them:
Have cleaning and inspections ever been increased at this location? El Yes[] No ❑NA ❑NE
Explain.
CS-SSO Form October 9, 2003 Page 2

Rhat corrective actions have been taken to reduce or eliminate I & I related overflows at this spill location
within the last year?
Has there been any flow studies to determine 1/1 problems in the collection system at the -SSO location? DYesD No DNA D NE
If Yes, when was the study completed and, what actions did it recommend?
Has the line been smoke tested or videoed within the past year? ❑YesD No DNA ❑NE
If Yes, when and indicate what actions are necessary and the status of such actions:
Are there 1/1 related projects in your Capital Improvement Plan? ❑YesD No DNA DNE
If Yes, explain:
Have there been any grant or loan applications for 1/1 reduction projects? ❑YesD No DNA El NE
If Yes,. explain:
Do you suspect any major sources of inflow or cross connections with storm sewers?
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream been inspected recently?
If Yes, explain:
❑YesD No[INAONE
YesD No DNA DNE
What other corrective actions are planned to prevent future 1/1 related SSOs at this location?
Comments:
Pump Station Equipment Failure (Documentation of testing, records etc
shoul be provided upon request.)
What kind of notification/alarm systems are present?
Auto-dialer/telemetry (one-way communication) ❑Yes
CS-SSO Form October 9, 2003 Page 4

als about. grease been distributed in the past?
and to whom?
Explain?
If the SSO occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation?
Were the floats clean?
Comments:
Roots
Do you have an active root control program?
0YesE1 No DNA ONE
❑YesO No ❑NA ❑NE
❑YesO No0NA0NE
Describe
Have cleaning and inspections ever been increased at this location because of roots? ❑YesEl No ❑ NA ❑ NE
Explain:
What corrective actions have been accomplished at the SSO location (and surrounding system if
associated with the SSO)?
What corrective actions are planned at the SSO location to reduce root intrusion?
Has the line been smoke tested or videoed within the past year? OYesO No ❑ NA ❑ NE
If Yes, when?
Comments:
Inflow and Infiltration /L
Are you under an SOC (Special Order by Consent) or do you have a schedule in any permit that ❑Ye No O NA O NE
addresses I/I?
CS-SSO Form October 9, 2003 Page 3

SCADA (two-way communication)
Emergency Contact Signage
Other
Describe the equipment that failed?
Yes
❑ Yes
❑ Yes
❑ Yes
❑ Yes
What kind of situations trigger an alarm condition at this station (i.e. pump failure, power failure, high
water, etc.)?
Were notification/alarm systems operable? ❑YesO No El NA ONE
If no, explain:
If a pump failed, when was the last, maintenance and/or inspection performed?
What specifically was checked/maintained?
If a valve failed, when was it last exercised?
Were all pumps set to alternate? ❑YesO No DNA ONE
Did any pump show above normal run times prior to and during the SSO event? ❑YesO No ONA ONE
Were adequate spare parts on hand to fix the equipment (switch, fuse, valve, seal, etc.)? ❑YesO No D NA D NE
Was a spare or portable pump immediately available? ❑YesO No DNA ❑NE
If a float problem, when were the floats last tested? How?
If an auto -dialer or SCADA, when was the system last tested? How?
Comments:
CS-SSO Form October 9, 2003 Page 5

jFuta a Documentation of testing, records, etc., should be
ded of alternative power source upon request.),
What is your alternate power or pumping source?
Did it function properly? ❑Yes❑ No DNA ❑NE
Describe?
When was the alternate power or pumping source last tested under load?
If caused by a weather event, how much advance warning did you have and what actions were taken to
prepare for the event?
Comments: .
Vandalism
Provide police report number:
Was the site secured? ❑Yes' ' No ❑NA FINE
If Yes, how?
Have there been previous problems withvandalism at the SSO location? - [:]Yes[—] No ❑ NA ❑ NE
If Yes, explain:
What security measures have been put in place to prevent similar occurrences in the future? ❑Yes❑ No ❑NA ❑NE
Comments:
Debris in line (Rocks, sticks, rags and other items not allowed in the
collection system, etc.)
What type of debris has been found in the line?
How could it have gotten there?
Are manholes in the area. secure. and intact? ❑Yes❑ No ❑ NA ❑ NE .
CS-SSO Form- October 9, 2003 Page . 6

e area last checked/cleaned?
ave cleaning and insAlld—
pections ever been increased at this location due to previous problems with debris? ❑Yes❑ No ❑NA ❑NE
i
Explain:
Are appropriate educational materials being developed and distributed to prevent future similar ❑Yes❑ No DNA ❑ NE
occurrences?
Comments:
Other (Pictures and a police report should be available upon request.)
Describe:
Were adequate equipment and resources available to fix the problem? ❑Yes❑ No ❑ NA ❑ NE
If Yes, explain:
If the problem could not be immediately repaired, what actions were taken to lessen the impact of the
SSO?
Comments:
For DWQ Use Only:
DWQ Requested an Additional Written Report: ❑Yes❑ No ❑NA ❑NE
If Yes, What Additional Information is Needed:
Comments:
0
CS-SSO Form October 9, 2003 Page 7'

resentative for the responsible
e best of my knowledge.
Person submitting claim:
hat the inf
tained in this report is true and accurate
Signature: flaaV V Title:
Telephone Number:
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five days of first
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of this form
is completed, if used).
CS-SSO Form October 9, 2003 Page 8

Notice of Discharge of Untreated Sewage
The Linville Land Harbor Property Owners Association had a discharge of sewage
from our wastewater treatment plant, pump station and sewer main located at
180 Overlook Road of approximately 15,000 gallons. The discharge was first
discovered on September 16, 2004 at 10:00 p.m. and lasted for approximately 96
hours. The untreated wastewater entered the Linville River of the Catawba River
basin. The treatment plant, pump station, and sewer main were repaired and back
in operation by 4:00 p.m. on September 20, 2004. This notice was required by
North Carolina General Statutes Article 21 Chapter 143.215.C.

V,�
Irvo';
Form CSJe C®Ilecti®D
K
Discharae/OvdAnv
WATER ONAUTY SECTION
_. I r- RFrIONAL OFFICE
ustificati®n Claim Form
The Director, Division of Water Quality, will take enforcement action for sanitary sewer system
discharges that required to be reported to the Division unless it is demonstrated that:
I) t e discharge was caused by severe natural conditions and there were no feasible alternatives to the
discharge;
or
(2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable
control of the Permittee and/or owner, and the discharge could not have been prevented by the exercise of
reasonable control.
This form maybe used to demonstrate (1) or (2) above. This claim form and apPropriate anchm nts should
submitted to the. Regional Office along with the Reporting Form within 5 working days of the date of the first
knowledge of the discharge/overflow in order to be considered for immunity from enforcement action by the
Division.
Permittee: b-J��erm.it�Qc2✓d✓ ��Number. ,c,16 QI o--2- % ,sSf7%
First knowledge of incident: (Date/Time) %,r/®o
AN,5VvI=K 9 HE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN THE CSR FORIN AND
INCLUDE THE APPROPRIATE DOCUMENTATION
Severe Natural Condition ( 24hr/25yr storm, hurricane, tornado, etc.)
jjDescribe the"severe natural condition" in detail. �0 p����� v,� C�`����c� j
//Was4 jr
`this con Xri occurred this area fore? Yes No If Yes, when?
Comments:
Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule in your permit that addresses I&I? F-1
v _ No
iw
Explain if Yes:
What corrective actions have
been accomplished that are associated with the spill locatio within the last year? Uo C)
What corrective actions are planned to prevent future spills at this location? r
t,,'--ldr �c� c�//����`
� c.�ra�'�%v y s �� ���v� .��� �v 4� �---�
Has the line been smoked or videoed within the past year?Ej Yes No If Yes, when?
Comments: _ /% / f
(� e- 11 4 eoC vZ f 1
&d e �I �v�? Arv0
��oke->u e5
.5" y-5 '-1-eI,
r)R A FT ('CT Fes,-.,, R.f—')Q ')nnz r,n A r r

\O�0F WAT �R�G
> 1
o r
The Reporting form must be submitted to the DWQ Regional Office within five working days of the first
knowledge of the discharge%verflow.
Perm.ittee: Oe_j jA vV Facility: G©t (?'- CvT '0P') 6 ys 4e",'
Permit Number (WQCS# if active, otherwise use treatment plant NC/WQ#): /116 O 7!.;;L J 1'5' 7
City: tj ex4ikJ
County: Av e-i''*—t
SPECIFIC location of spill/bypass (be consistent in nomenclature from past reports or documentation):
Latitude/Longitude (if available):
First knowledge of incident: (Date/Time) ��� / d)Pfi✓ 7
Incident Ended: (Date/Time):/tV,0V/4/1,, 544stimated Duration (Time): 1,92- 413'
Estimated volume of spill/bypa#)r(91'0
gallons. Show rational for volume: � j•�- `
df spill is ongoing, please notify Regional Office on a daily basis until spill can be stopped.
Reported to: -� r WQ Ej Emergency Mgmt_ (Date/time) /
Name of person
Weather conditions:
Source of spilUbypass (check one): �Sa-ewer Pump Station WWTP
Level of treatment (check one): None Primary Treatment Secondary Treatment Disinfection Only
Did spill/bypass reach surface waters? es eo (If Yes, please answer the following)
Volume reachin- surface waters?/Pallons
Name of surface water 'V mop �-L /..L �(�/ I V-e-
Did spillibypass result in a fish kill? Yes [�'NO ` `
If Yes, what is the estimated number of fish killed?
SPECIFIC cause of spilUb ass:
Severe Natural Condition
Inflow and Infiltration
Grease
Vandalism
Debris in line
❑ Roots
Equipment failure
Power outage
❑ Other uncommon event
Explain:
l certify that the information contained in this report is true and accurate to the best of my knowledge.
Person submitting report: l s Date: �
74
ture: eoze!�

7
Y
Form CSR: Collection System Discharge/Overflow Reporting Form
(REQUIRED)
The Reporting form must be submitted to the DWQ Regional Office within five working days of the first
knowledge of the discharge%verflow.
Permittee: i / `"�iJ��f� Facility:�i���/ r
Permit Number (WQCS#if active,(f otherwise use treatment plant NC/WQ#): /&, 06 �;L /16-7
City: %ldew 1,4^4 County: Atery .
SPECIFIC location of spill/bypass (be consistent in nomenclature from past reports or documentation):
Latitude/Longitude (if available): p p
First knowledge of incident: (Date/Time)
Incident Ended: (Date/Time): 5e' -// (i t�: h Estimated Duration (Time): 9 AY-5
Do
Estimated volume of spill bypass- 61 gallons. Show rational for volume: 5S �;07,--4 @_
If spill is ongoing, please noti Regional Office on a daily basis until spill can be stopped.
Reported to: -eApe DWQ ❑ Emergency Mgmt. (Date/time)
j
-
Name of person
Weather conditions: _5C V —et"-(f'.
Source of spill/bypass (check one): ❑ Sanitary Sewer ❑ Pump Station TP
Level of treatment (check one): ❑ None rimary Treatment ❑ Secondary Treatment ❑ Disinfection Only
Did spill/bypass reach surface waters? J2,'Tes ❑ No (If Yes, please answer the following)
Volume reaching surface waters?J a gallons
Name of surface water���
Did spill/bypass result in a fish kill? ❑ Yes i/ No .
If Yes, what is the estimated number of fish killed?
SPECIFIC cause ;�Slevere
ass: Natural Condition
❑ Inflow and Infiltration
❑ Grease
❑ Vandalism
❑ Debris in line
❑ Roots
❑ Equipment failure
❑ Power outage
❑ Other uncommon event
Explain:
I certify that the information contained in this report is true and accurate to the best of my knowledge.
Person submitting report: e� /—&4 ems. Date: Cl , (?, 6V
ature:
__ . __ .--- — . I--- nil IA— T n n r'T

O�DF W ATF9oG
N 7
> ULMx
o �
t-orm GSJ: Collection
ow Justification Claim
The Director, Division of Water Quality, will take enforcement action for sanitary sewer system
discharges that required to be reported to the Division unless it is demonstrated that:
39 he discharge was caused by severe natural conditions and there were no feasible alternatives to the
discharge;
or
(2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable
control of the Permittee and/or owner, and the discharge could not have been prevented by the exercise of
reasonable control.
This form may be used to demonstrate (1) or (2) above. This claim form and appropriate attachments should be
submitted to the Regional Office along with the Reporting Form within 5 working days of the date of the first
knowledge of the discharge/overflow in order to be considered for immunity from enforcement action by the
Division. n
Permittee.- OeAlf>Permit Number. 0 cg,'(-b��
First knowledge of incident: (Date/Time) See4— Y-7 %r 0& Af''----`
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN THE CSR FORM AND
INCLUDE THE APPROPRIATE DOCUMENTATION
Severe Natural Condition ( 24hr/25yr storm, hurricane, tornado, etc.)
Describe the "severe natural condition" in detail.
/- - ✓ n✓ -*- d 74-74-t1:r /-ee4;-e1e,,P
Has this condition occurred in this area before? Yes No If Yes, when?
Comments:
Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule in your permit that addresses I&I?
Yes Ci No
Explain if Yes:
What corrective actions have been accomplished that are associated with the spill location within the last year?
What corrective actions are planned to prevent future spills at this location? C"(P 9 rhile— 6 i 5 ri fV�
Has the line been smoked or videoed within the past year? 0 Yes No If Yes, when?
Comments:
744 G
DRAFT CSJ Form Mav 23. 2003 DRAFT

o�oF warFgoG
Form CSR: Collection System Discharge/Overflow Reporting Form
Y (REQUIRED)
The Reporting form must be submitted to the DWQ Regional Office within five working days of the first
knowledge of the discharge%verflow.
I ermittee: w O /Ve_a) 14A,;Cl Facility:
Permit Number (WQCS#'if active, otherwise use treatment plant NC/WQ#): A16 C C; -
City: A,%� iA) M il✓d
County: AfPeI ,p—Le
SPECIFIC location of spill/bypass (be consistent in nomenclature from past reports or documentation): OCA 7-eJ v -if-
/
Latitude/Longitude (if available): � E�'T.3 r -e 1-4Ar- e—,
First knowledge of incident: (Date/Time) . 31, d ryni Sep i` 7
Incident Ended: (Date/Time): �r 00-1M- S r Estimated Duration (Time): 37 Xt-5
Estimated volume of spill/bypass/do. ®C gallons. Show rational for volume: E"- 4 b►'4c
df spill is ongoing, please notes Regional Office on a daily basis until spill can be stopped.
Reported to: }J- � WQ Emergency Mgmt. (Date/time) 7/3
Name of person
Weather conditions: _5!e vet
Source of spill/bypass (check one): Sanitary Sewer vlpl�p Station 0 WWTP
Level of treatment (check one): VNIone 0 Primary Treatment 0 Secondary Treatment Disinfection Only
Did spill/bypass reach surface waters? 'es No (If Yes, please answer the following)
Volume reaching surface waters?/®0'©gallons
Name of surface water IVD.,;-
Did spill/bypass result in a fish kill? Yes o
If Yes, what is the estimated number of fish killed?
SPECIFIC cause of spill/bypass:
Severe Natural Condition
Inflow and Infiltration
❑ Grease
Vandalism
[] Debris in line
Roots
Equipment failure
F] Power outage
❑ Other uncommon event
Explain:
1 certify that the information contained in this report is true and accurate to the best of my knowledge.
Person submitting report: ��� Date: �,,� q
o
Sig-naIure:

Form CSJ: Collection
e/Overflow Justification Claim Form
The Director, Division of Water Quality, will take enforcement action for sanitary sewer system
discharges that required to be reported to the Division unless it is demonstrated that:
Pe discharge was caused by severe natural conditions and there were no feasible alternatives to the
discharge;
or
(2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable
control of the Permittee and/or owner, and the discharge could not have been prevented by theLexercise of
reasonable control.
hic, f m - b 'se to d ( ) or ` .)21 a CV.,. Th:s C ri.• an appTopri«te attaCl :::^fits ihCuid u�
T Orn: air C j.. d P^:O.^.Strate i U
submitted to the Regional Office along with the Reporting Form within 5 working days of the date of the first
knowledge of the discharge/overflow in order to be considered for immunity from enforcement action by the
Division.
Permittee:
Permit Number:
First knowledge of incident: (Date/Time) /
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED -IN THE CSR FORM AND
INCLUDE THE APPROPRIATE DOCUMENTATION
Severe Natural Condition ( 24hr/25yr storm, hurricane, tornado, etc.)
Describe the "severe natural condition" in detail. I-D tk e, +t, tV O p , CA
Has this condition occurred in this area before? Yes R No If Yes, when?
_ Comments:
I1/(fJ6-r' )4'< d 6 6e, ver-e—
Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule in your permit that addresses I&I? [�
Yes ❑ No.
Explain if Yes:
What corrective actions have been accomplished that are associated with the spill location within the last year?
What corrective actions are planned to prevent future spills at this location? file° j P -9dw—, cq-,C fD",,
Has the line been smoked or videoed within the past year? 0 Yes 0 No If Yes, when?
Comments: 1-4 +n' ;N 5'�'�' �/v �� / /y SG/� �a'�- - 17 Y
r)P AFT i"C T 17- Vf— - 2 -Mn -I ran n I=

I8 pp E Form CS-SSO
n
Utary Sewer Overflow Reporting Form
„-., � 0��„n t PART I
This form shall be submitted to the appropria a D111 Q Regional Office wit in fi days of the first knowledge of
the sanitary sewer overflow (SSO). WATER QUALITY SECTION
Permit Number: (� �j� r` (� ASHEVILLE REGIONAL OFFICE
(WQCS# if active, otherwise use treatment plant NC/WQ#)
Facility. t�h��'� ���I.IR���n�1�rn Incident#
Owner:'T� /� i`[4r�r�a''I� Region:
city: C�r/, i l County: z�/ Ica
Source of SSO (check applicable) : 0 Sanitary Sewer
SPECIFIC location of the SSO (be consistent in descri tion from
Manhole at Westall & Bragg Street, etc.) : �l K 4' a-e.
Latitude (degrees/minute/second):
Incident Started Dt: ` 1706 Time: Z On Am
(mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: �S Zen gallons
Pump Station
reports or documentation - i.e. Pump Station 6,
Long itude(deg rees/m in ute/second)-
Incident End Dt: "ZD -20 4 Time- SL22 f2n3
(mm-dd-yyyy) hh:mm AM/PM
Estimated Duration (Round to nearest hour): �134
Describe how the volume was determined: 20�Jq,Pr'' � , �5 m; r1, Gi�g-k kour
Weather conditions during SSO event: �1Pv.Q �p� l / ��n�i 0:4
Did SSO reach surface waters? .R Yes ❑ No ❑ Unknown Volume reaching surface waters (gallons):
Surface water name: �1�' %►�Q �� 0"-ee-
Did the SSO result in a fish kill? ❑ YesXNo Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
XSevere Natural Condition
El Inflow and Infiltration
El Vandalism
Immediate 24-hour verbal notification reported to:
0 DWQ �K Emergency Mgmt.
El Grease ❑ Roots
El Pump Station Equipment Failure ❑ Power outage
El Debris in line Other (Please explain in Part II)
Date (mm-dd-yyyy): / cL Time (hh:mm AM/PM):
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003
Page 1

Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
PART I I
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN PART I OF THIS FORM
AND INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN PART I
In the check boxes below, NA = Not Applicable and NE = Not Evaluated
A HARDCOPY OF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWQ REGIONAL OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Severe Natural Condition (hurricane, tornado, etc.
Describe the "severe natural condition" in detail.
welp��-ComC :�Z ao4 —
How much advance warning did you have and what actions were taken in preparation for the event?
Comments:
Grease (Documentation such as cleaning, inspections, enforcement
actions, past overflow reports, educational material and distribution date,
etc. should be available upon request.)
•—
m . �c� 51 �n� GdO� o�4rr,�ped jL
�P�P�ed �u�L�•�� WQs ��rdi�y' ,e,�.o
When was the last time this specific line (or wet well) was cleaned?
Do you have an enforceable grease ordinance that requires new or retrofit of grease traps/interceptors? ❑Yes❑ No ❑ NA ❑ NE
Have there been recent inspections and/or enforcement actions taken on nearby restaurants or other ❑Yes❑ No ❑NA❑NE
nonresidential grease contributors?
Explain.
Have there been other SSOs or blockages in this area that were also caused by grease? ❑Yes❑ No ❑NA ❑ NE
When?
If yes, describe them:
Have cleaning and inspections ever been increased at this location? ❑ Yes[—] No ❑ NA ❑ NE
Explain.
CS-SSO Form October 9, 2003 Page 2

aterials about grease been distributed in the past?
and to whom?
Explain?
If the SSO occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation?
Were the floats clean?
Comments:
Roots
Do you have an active root control program?
Describe
❑Yes❑ No❑NA❑NE
❑Yes❑ No❑NA❑NE
❑Yen No❑NA❑NE
Have cleaning and inspections ever been increased at this location because of roots? ❑Yes❑ No ❑ NA ❑ NE
Explain
What corrective actions have been accomplished at the SSO location (and surrounding system if
associated with the SSO)?
What corrective actions are planned at the SSO location to reduce root intrusion?
Has the line been smoke tested or videoed within the past year? ❑Yes❑ No ❑ NA ❑ NE
If Yes, when?
Comments:
Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule in any permit that ❑ Yes❑ No ❑ NA ❑ NE
addresses 1/1?
CS-SSO Form October 9, 2003
Page 3

�Vhat corrective actions have been taken to reduce or eliminate I & I related overflows at this spill location
within the last year?
Has there been any flow studies to determine 1/1 problems in the collection system at the SSO location? ❑Yes❑ No ❑ NA ❑ NE
If Yes, when was the study completed and what actions did it recommend?
Has the line been smoke tested or videoed within the past year? ❑ Yes❑ No ❑ NA ❑ NE
If Yes, when and indicate what actions are necessary and the status of such actions:
Are there 1/1 related projects in your Capital Improvement Plan? ❑ Yes❑ No ❑ NA ❑ NE
If Yes, explain:
Have there been any grant or loan applications for 1/1 reduction projects? ❑Yes❑ No ❑ NA ❑ NE
If Yes, explain:
Do you suspect any major sources of inflow or cross connections with storm sewers? ❑ Yes❑ No ❑ NA ❑ NE
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream been inspected recently? ❑ Yes❑ No ❑ NA ❑ NE
If Yes, explain:
What other corrective actions are planned to prevent future 1/1 related SSOs at this location?
Comments:
Pump Station Equipment Failure (Documentation of testing, records etc.,
shoul be provided upon request.)
What kind of notification/alarm systems are present?
Auto-dialer/telemetry (one-way communication)
❑ Yes
CS-SSO Form October 9, 2003 Page 4

edible
3ual
SCADA (two-way communication)
Emergency Contact Signage
Other
❑ Yes
❑ Yes
❑ Yes
❑ Yes
❑ Yes
Describe the equipment that failed?
What kind of situations trigger an alarm condition at this station (i.e. pump failure, power failure, high
water, etc.)? Were notification/alarm systems operable? El Yen �-I
No ❑ NA ❑ NE
If no, explain:
If a pump failed, when was the last maintenance and/or inspection performed?
What specifically was checked/maintained?
If a valve failed, when was it last exercised?
Were all pumps set to alternate?
Did any pump show above normal run times prior to and during the SSO event?
Were adequate spare parts on hand to fix the equipment (switch, fuse, valve, seal, etc.)?
Was a spare or portable pump immediately available?
If a float problem, when were the floats last tested? How?
If an auto -dialer or SCADA, when was the system last tested? How?
Comments:
CS-SSO Form October 9, 2003
❑Yes❑ No DNA ❑NE
❑ Yes❑ No ❑ NA ❑ NE
❑Yen No❑NA❑NE
❑YesEl No ❑ NA ❑ NE
Page 5

Itage (Documentation of testing, records, etc., should be
of alternative Dower source LlDon reauest.)
is your alternate power or pumping source?
Did it function properly? ❑Yes❑ No❑NA❑NE
Describe?
When was the alternate power or pumping source last tested under load?
If caused by a weather event, how much advance warning did you have and what actions were taken to
prepare for the event?
Comments:
Vandalism
Provide police report number:
Was the site secured?
If Yes, how?
❑ Yes[] No ❑ NA ❑ NE
Have there been previous problems with vandalism at the SSO location? ❑ Yes❑ No ❑ NA ❑ NE
If Yes, explain:
What security measures have been put in place to prevent similar occurrences in the future? ❑ Yes❑ No ❑ NA ❑ NE
Comments:
Debris in line (Rocks, sticks, rags and other items not allowed in the
collection system, etc.)
What type of debris has been found in the line?
How could it have gotten there?
Are manholes in the area secure and intact? ❑ Yen No ❑ NA ❑ NE
CS-SSO Form October 9, 2003 Page 6

ast checked/cleaned?
ispections ever been increased at this location due to previous problems with debris?
Explain:
❑Yes❑ No❑NA❑NE
Are appropriate educational materials being developed and distributed to prevent future similar ❑ Yes❑ No ❑ NA ❑ NE
occurrences?
Comments:
Other (Pictures and a police report should be available upon request.)
Describe:
Were adequate equipment and resources available to fix the problem? ❑ Yes[] No ❑ NA ❑ NE
If Yes, explain:
If the problem could not be immediately repaired, what actions were taken to lessen the impact of the
SSO?
Comments:
For DWQ Use Only.
DWQ Requested an Additional Written Report:
❑ Yes[—] No ❑ NA ❑ NE
If Yes, What Additional Information is Needed:
Comments:
CS-SSO Form October 9, 2003 Page 7

for the responsible party, I certify that the information contained in this report is true and accurate
best of my kn
Person submitting claim:
Date: ! , 2,� — D
I Si ,dw,
nature: AAte✓ `'��U
g t'Nt Title:
Telephone Number: C�j Z �� 16 —,,t53 l
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five days of first
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of this form
is completed, if used).
CS-SSO Form October 9, 2003 Page 8

1J ;I1� rrsurt-AUVtNt1 AStit:VlLbh EU
2S'Lb'LyVO4�i
'1'-y'f1 YN'LJI�y U-yy1
Form CS-SSO
Reporting Form
This Form shall be submitted to the a rgH CR QUALITY��
P)W8ft1A�fe ithin ive da s o first knowledge of
the sanitary sewer overflow (SSO).
Permit Number, 1�4J
(W CS# if active, otherwise use treatment plant NC/WQ#)O
Facility: �ek J_q 4d 4L
Incident #
Owner: Ge?Le Jr., i¢rr.•ti, %/ v er /✓��oad —
Region:
CRY' County:
Source. of SSO (check applicable) : 2r- Sanitary Sewer
0 Pump Station
reports or documentation -;.e. Pump Station 0.
Longitude(degreeslminutefsecond)• ��� �-�,p
Incident End Dt• % Time:7 L__L-A-7
(+'w*dd-yyyy) hh:mm AM/PM
Estimated Duration (Round to nearest hour) _2
Describe how the volume was determined: /"W 4 a 4 Vr-,i G,
Weather conditions during SSO event: Gleu 1-�
Did $50 reach surface waters? ❑ Yes�No Wi Unknown �/cb�r�f y'�olume reaching surface waters (gallons):
Surface water n laIme; �G°)rP Tin �. /c[ /I N /
Did the S50 resr It In a fish kill? Cl Yes qNo ❑ Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC causes) of the 550:
❑ Severe Natural Condition
Inflow and Infiltration
❑ .Vandallsm - ---
i
Immediate 24-Wvr verbal notification reported to:
❑ DWQ P Emergency Mgmt,
SPECIFIC location of the SSO (bo consistent in d
Manhole at West all & Bragg Street, etc.)!—"
Latitude (dGarees/rr inutA/.qarnnril-
Incident StartedDt: Time- Lf
in�m•dd-yyyy) hh,nun AMIFM
Estimated volume of the SSO: —� gallons
WGrease Q Roots
❑ Pump Station Equipment Failure ❑ Power outage
0 Debris in line' ❑ Other (Please explain in Part Ill
e /k s
Date(mm-dd-yyyy): QTime (hh:mmAM/PM): °I-.3�,/,��J
-If an 18SO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to. surface
waters shall Issue a pressreleese within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county w ere a rscharge occurred. When 15,ODO gallons or more of untreated wastewater enters surface
wafers, a public notice shall be published. within 10 days and proof of publication shall be provided to the Division within 30 days,
Refer to the referenced statute for further detail,
take enforcement action for SSOs that are
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge: or
2) the discharge liras exeeptiomal, unintentional, temporary and caused by factors beyond the reasonable control of the Permitlee
and/or owner, and the discharge oould not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations, This Information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART it IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003
Pape 1

19
FROM-NCDENR ASHEVILLE RO 8282997043
T-971 P03/09 U-991
Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
PART I I
FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN PART I OF THIS FORM
- - ..v..,�I THE APPROPRIATE DOCUMFNTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN PART I
In the chack boxes below, NA = Not Applicable and NE = Not Evaluated
A HARDCOPYIOF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWQ REGIONAL OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Severe Natural Condition hurricane, tornado, eta.
Describe the "severe natural condition" in detail.
How much advariee warning did you have and what actions were taken in preparation for the event?
Comments;
Grease
such
educational material and
etc. should be.lavailable upon. re hest
When was the last tuns this specific line (or wet well) was cleaned?
iI
Do YOU have an enforceable grease ordinance that requires new or retrofit of grease traps/interceptors? IgYesU No1�NA0NE
J kla'y,jejj/, Ile w1v )4YPcllJ fr ,1 Have there. been �eeent inspections andlor enfgrwment actions taken on nearby restaurants or other IYZ No u NA ©NE
nonresidential grease contributors?
y
i �'''
Have there been ether SSOs or blockages in this area that were also caused by grease? ®YZ NOU NA ONE
When? ,T Z �v `l
rj eel
If yes, describe them ��/�`r�d / J �e CAry Z J
Hgve cleaning and inspections ever bean increased at this location? 19ya,0 No EINAQMp
Explain. r/1J i j�P 4 ` I///1 ✓Pl �rte
✓'l'r��
//?, G.�PCl/9l'�
-'/L®Q/G'-
tG1��C 11 l�e6,,A11
j2 111-
C% /
41O
/ h ft�lrllell
CS•SSO Fowl October 9, 2003
e 2

16:40 tMILIM-AIJO h AbhhV1LLh EU iiL25'L�y'I104i
materials about grease been distributed in the past?
When? J� ry /D /°�OD
and to whorn7 'Ile u f- j6'6111V
Explain? �T 1"{�/' ✓�, �Y Z �tr��
if the SSO occurred. at a purnp station, when was the wet well and purillps
accumulation?
Were the floats dean?
Comments:
Roots
i
Do you have an active root control program?
Describe
last checked for grease
Have cleaning and Inspections ever been increased at this location because of roots?
Explain:
What corrective actions have been accomplished at the SSO location (and surrounding system if
associated. with tl1e SSO)?
I
What corrective actions. are planned at the. SSO location to reduce root Intrusion?
Has the line beer] smoke tested or videoed within the past year?
If Yes, when? 1
Comments:
'I*-y"f1 1 04 0J U-y�jl
0 Yes[] No LJ NA ❑ NE
❑Yes❑ No ❑NA❑NE
❑Yes❑ No[UNA❑NE
NE
No tJ NHS tJ NE
Inflow and Infiltration
Are you under an! SOO (Special Order by Consent) or do you have a schedule In any permit that ❑Yes le ❑NA ENE
addresses I/I?
CS-S$Q Form October 9; 2003 Page 3

15 ; L'tl 1"tiUl"J—Nl:lll Nti HStilrVlLL1" tiU
Explain if Yes:
6z2S'f.yy704�i
1-y f 1 r1 nMj U-".L
'e acuons nave been taken to reduce or eliminate I & I related overflows at this spill Location
year?
Has there been any flow studies to determine III problems in the collection system at the $SO location?
If Yes„ when iwaa the study completed and what actions did it recommend?
Has the line been smoke tested or videoed within the past year? YesVLNo NA NE
If. Yes, when and indicate what actions are necessary and the status of such actions:
Are there 1/1 related projects in your Capital Improvement Plan? Yost N. El NA U NE
i
If Yes, explaii n:
Have there bi6en any grant or loan applications for Ill reduction projects? []Yes,KNo NA NE
If Yes, explain:
Do you suspect any major sourcos of inflow or Gross connections with storm sewers? ❑Yee No ❑NA ONE
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream been Inspected recently? ❑YesO No WNA ONE
If Yes, explain:
What other corrective actions are planned to prevent future III related SSOs at this location?
//`r 1 '-
Comments:
Pump Station Equipment Failure (Documentation of testing, records etc.
s_houl be ptbvided upon request.)
What kind of notification/alarm systems are present?
Auto-dialer/telemetry (one-way communication)
08-350 Form October 9, 2003
[]Yes
Page 4

13:21 FROM-NMENR ASHEVILLE RO
i
i
Audible
Visual
SCADA (two-way communication)
Emergency Contact Signage
Other
Describe the equipment that failed?
8282997043
T-9'r "1 FIM lily . U-yy1
QYcs
Oyes
❑Yes
Dyes
❑Yes
What kind of situationd trigger an alanr condition at this station (Le. pump failure, power failure, high
water, etc.)?
Were notification/alarm systems operable?C1 Yes Na KNA LJ NE
If no, explain:
If a pump failed; when was the last maintenance and/or Inspection performed?
what specifically, was checked/maintainod?
If a valve failed,�when was it last exercised?
I
Were, all pumpsisot to alternate? 13YesO No ®NA ONE
i
Did any pump show above normal run times prior to and during the $SO event? QYea[:] No 1A ONE
Wars adequate (spare parts on hand to fix the equipment (switch, fuse, valve, seal, etc.)? DY.0 No[RNA ONE
i
Was a spare or portable pump immediately available? DY.D No aNA ONE
If a float problem, when were the floats last tested? How?
i
If an auto-dialer'or SCADA, when was the system last tested? How?
comments:
CS-SSO Form October 9, 2003
Page 5

1 FHOM-NUDENE ASHEVILLE EO 8282997043 T-971 P07/09 U-391
Proviaea of aternatiye. power source upc
What is your alternate power or pumpino source?
Did it function properly?
Describe?
When was the alternate power or pumping source last tested under load?
If caused by a weather event, how much advance warning. did you have and what actions were taken to
prepare for the event?
Comments;
Vandalism
Provide police report number;
Was the site secured? 11YeSO No,IGU NA D NE
If Ync hntu9
.Padlocked Ctntrol Panel
Have there been p'revlous problems. with vardviism at the SSO location? LJYesU NohfNAUNE
If Yes, explain:
i
What security measures have been put in place to prevent similar occurrences In the future? DYesD No A D NE
Comments:
Debris in line (Rocks, sticks, raps and other items not allowed in the
collection system, oiC, )
What type of debr4 has been found in the line?
How could it have gotten there?
Are manholes in the area secure and intact? UYOsU NoLKNAL.FNE-
M8 55O Form October 9. 2003 Page 6

16:Ze MUM-MiDENN ASNhV1LL1~ NU S2SZ597043 T-Va F08/09 U-9K
i
was the area last checked/cleaned?
Have cleanino aitd inspections aver been Increased at this beafion due to previous problems with debris? 1JYe1D No.9�NA ❑NE
Explain;
Are appropriate educatlonal materials being developed and distributed to prevent future similar uYea� No NA ONE
occurrences?
Comments:
Other (Pictures and S. police report should be available upon request )
Describe:
I
Were adequate oqulpment and resources available to fix the problem? n YesO N NA NE
If Yes, explain:
If the problem cvyld not be Immediately repaMd, what actions were taken to lessen the impact of the
SSO?
Uomments:
:R
For. DWQ Usel,Only:
DWQ Requested an Additional Written Report;
If Yes, What Addltlonal Information is Needed:
i
comments:
DYaap l NoEINA EINC-
08-980 Form October 9, 2003 Page 7

c� rrturrNl�llrNH A5HhVILLh HU Kii'LyyYM
'I"VI 1'0M) 1-1-y11
to the beat of my knowied9e
Person submitting claim: 10- Fc 4e (( Xf �ocf y y
J
Signature:
contained in this reP ort Is true and accurate
Date: �(-Z 0 '- d
Title: g7 -
Telephone Number:
Any additional information desired to be submitted should be sent io the appropriate Division RegiQnal Office within five. days of first
knowledge of the SSQ with refQrence to the incident number {the incident number is only generated when electronic entry Qf this form
is completed, if used).
i
CS-SSO Form October 0, 2003 Page 8

ZD�Q
This form shall be submitted to the approp
the sanitary sewer overflow (SSO).
Reporting Form
of the first knowledge of
Permit Number: (WQCS# if active, otherwise use treatment plant NC/WQ#)
Facility, r'eQi ��>j�P ���oFi �� Incident# 2.60 46 19
Owner: 1 ocaJ ra �%� n �'1P �� IC Region:
City: County:ype�
Source of SSO (check applicable) : Sanitary Sewer Pump Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation - i.e. Pump Station 6,
Manhole at Westall & Bragg Street, etc.) : G� lC►lr�p. �j iww'�4 ��vr-�
Latitude (degrees/minute/second): Long itude(degrees/m inute/second):
Incident Started Dt: 2-7 -Z��a Time: 0: 30 /n
(mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: !24 gallons
N v ow, I I
Describe how the volume was determin
Weather conditions during SSO event:
Did SSO reach surface waters? L!N Yes LJ No LJ Unknown
Surface water name: �) We head Ceee.K
Did the SSO result in a fish kill? El Yes ® No Unknown
SPECIFIC cause(s) of the SSO:
Severe Natural Condition
® Inflow and Infiltration
❑ Vandalism
Immediate 24-hour verbal notification reported to:
0 DWQ 0 Emergency Mgmt.
Incident End Dt: !2' " Z42 2-/ Time: 7 0644
(mm-dd-yyyy) hh:mm AM/PM
Estimated Duration (Round to nearest hour)
Volume reaching surface waters (gallons): �jQ
If Yes, what is the estimated number of fish killed?
0 Grease
El Pump Station Equipment Failure
El Debris in line
Date (mm-dd-yyyy):
El Roots
El Power outage
EJ Other (Please explain in Part II)
Time (hh:mm AM/PM):
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003 Page 1

Collection System Sanitary Sewer Overflc
ANSWER THE FOLLOWING QUESTIONS.F.OR EACH RELATED CAUSE CHECKED IN PART I Or i nio rvrxivi
AND INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN PART I
In the check boxes below, NA = Not Applicable and NE = Not Evaluated
A HARDCOPY OF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWQ REGIONAL OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Severe Natural Condition (hurricane, tornado, etc.)
De/scribe the "severe natural condition" in detail.
/H,ow/ much advance warningdidyou have and what actions were taken in preparation for the event?
Comments: -¢fiE'
Grease -(Documentation such as cleaning, inspections, enforcement
actions, past overflow reports, educational material and distribution date,
etc. should be available upon request.)
When was the last time this specific line (or wet well) was cleaned?
Do you have an enforceable grease ordinance that requires new or retrofit of grease traps/interceptors?
Have there been recent inspections and/or enforcement actions taken on nearby restaurants or other
nonresidential grease contributors?
Explain.
❑Yes❑ No❑NA❑NE
❑Yes❑ No❑NA❑NE
Have there been other SSOs or blockages in this area that were also caused by grease? ❑Yes❑ No ❑ NA ❑ NE
When?
If yes, describe them:
Have cleaning and inspections ever been increased at this location?
Explain.
❑Yes❑ No❑NA❑NE
CS-SSO Form October 9, 2003 Page 2

terials about grease been distributed in the past?
ana to wnom r
Explain?
If the SSO occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation?
Were the floats clean?
Comments:
Roots
Do you have an active root control program?
Describe
❑Yen No❑NA❑NE
❑Yes❑ No❑NA❑NE
❑Yes❑ No❑NA❑NE
Have cleaning and inspections ever been increased at this location because of roots? ❑Yes❑ No ❑NA ❑NE
Explain:
What corrective actions have been accomplished at the SSO location (and surrounding system if
associated with the SSO)?
What corrective actions are planned at the SSO location to reduce root intrusion?
Has the line been smoke tested or videoed within the past year? ❑Yes❑ No ❑NA ❑NE
If Yes, when?
Comments:
Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule in any permit that ❑Yes® No ❑ NA ❑ NE
addresses 1/1?
CS-SSO Form October 9, 2003
Page 3

Explain if Yes:
What corrective actions have been taken to reduce or eliminate I & I related overflows at this spill location ,
within the last year?
�u� %17an bole ���s
Has there been any flow studies to determine 1/1 problems in the collection system at the SSO location? ❑YesKNo ❑NA ❑NE
If Yes, when was the study completed and what actions did it recommend?
Has the line been smoke tested or videoed within the past year? ❑ YX No ❑ NA ❑ NE
If Yes, when and indicate what actions are necessary and the status of such actions:
Are there III related projects in your Capital Improvement Plan? OYes❑ No El NA ❑NE
If Yes, explain:
el-lolQ 06
Have there been any grant or loan applications for 1/1 reduction projects? ❑Yesg No ❑NA El NE
If Yes, explain:
Do you suspect any major sources of inflow or cross connections with storm sewers? ❑ Yes�d No ❑ NA ❑ NE
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream been inspected recently? lelj Yell No ❑NA El NE
If Yes, explain:
Ae19 --e4
What other corrective actions are planned to prevent future 1/1 related SSOs /at this location?
�Gicse6( r� i n e d Ahl %o le Fd 4L) q, P&"' 69
Comments:
Pump Station Equipment Failure (Documentation of testing, records etc.,
shoul be provided upon request.)/
What kind of notification/alarm systems are present?
Auto-dialer/telemetry (one-way communication) RrYes
CS-SSO Form October 9, 2003 Page 4

iible
jai
SLHUH (two-way communication)
Emergency Contact Signage
Other
Describe the equipment that failed?
4olYeS
MYes
❑ Yes
kCgYes
❑ Yes
What kind of situations trigger an alarm condition at this station (i.e. pump failure, power failure, high
water, etc.)?
Were notification/alarm systems operable? ❑Yes❑ No ❑NA ❑NE
If no, explain:
If a pump failed, when was the last maintenance and/or inspection performed?
What specifically. was checked/maintained?
If a valve failed, when was it last exercised?
Were all pumps set to alternate?
Did any pump show above normal run times prior to and during the SSO event?
Were adequate spare parts on hand to fix the equipment (switch, fuse, valve, seal, etc.)?
Was a spare or portable pump immediately available?
If a float problem, when were the floats last tested? How?
If an auto -dialer or SCADA, when was the system last tested? How?
Comments:
❑Yes❑ No❑NA❑NE
❑ Yes❑ No ❑ NA ❑ NE
❑Yes❑ No❑NA❑NE
❑Yes❑ No❑NA❑NE
CS-SSO Form October 9, 2003
Page 5

Power outage (Documentation of testing, records, etc., should be
provided of alternative power source upon request.)
What is your alternate power or pumping source?
Did it function properly?
Describe?
When was the alternate power or pumping source last tested under load?
If caused by a weather event, how much advance warning did you have and what actions were taken to
prepare for the event?
Comments:
Vandalism
Provide police report number:
Was the site secured?
If Yes, how?
❑Yes❑ No❑NA❑NE
Have there been previous problems with vandalism at the SSO location? ❑Yes❑ No El NA El NE
If Yes, explain:
What security measures have been put in place to prevent similar occurrences in the future? ❑Yes❑ No ❑NA ❑NE
Comments:
Debris in line (Rocks, sticks, rags and other items not allowed in the
collection system, etc.)
What type of debris has been found in the line?
How could it have gotten there?
Are manholes in the area secure and intact? ❑Yesu No ❑ NA ❑ NE
CS-SSO Form October 9, 2003 Page 6

area last checked/cleaned?
cleaning and inspections ever been increased at this location due to previous problems with debris? ❑Yes❑ No ❑ NA ❑ NE
Explain:
Are appropriate educational materials being developed and distributed to prevent future similar ❑Yes❑ No ❑ NA ❑ NE
occurrences?
Comments:
Other (Pictures and a police report should be available upon request.)
Describe:
Were adequate equipment and resources available to fix the problem? ❑Yes❑ No ❑NA ❑NE
If Yes, explain:
If the problem could not be immediately repaired, what actions were taken to lessen the impact of the
SSO?
Comments:
For DWQ Use Only:
DWQ Requested an Additional Written Report: ❑Yes❑ No El NA ❑NE
If Yes, What Additional Information is Needed:
Comments:
CS-SSO Form October 9, 2003 Page 7

As a representative for the responsible
to the best of my knowledge.
Person submitting claim: ell V-r 5
I certify that the information contained in this report is true and acIR
Date:
Signature: C��% j ��. �> Title: /yf17 Cf'r Z.�k le l-
Telephone Number: eX�S)
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five days of first
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of this form
is completed, if used).
CS-SSO Form October 9, 2003 Page 8

ELEiVE C�
SEP 2 2 2004
� Form CS-SSO
C LCII Y ewer Overflow Reporting Form
ASHEVILLE REGIONAL OFFId6
PART I
This form shall be submitted to the appropriate DWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number: ° Qo/
(WQCS#if active, otherwise use treatment plant NC/WQ#)
f
Facility: Incident #
i
Owner: . '^ / Region:
City: County: �� z6fIV
Source of SSO (check applicable) : Sanitary Sewer Pump Station
SPECIFIC location of the SSO (be consist en 'n de cription from past reportsordocumentation - i.e. Pump Station E,
Manhole at Westall & Bragg Street, etc.) : ` 14, /! jt 1",P'C-LC
Latitude (degrees/minute/second):
c '� Incident Started Dt: � Time.'
(mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: —T/,o gallons
Describe how the volume was determined:
Weather conditions during SSO event: fi
Did SSO reach surface
Surface water name:
Did the SSO result in a fish kill?
Yes0NoF-1 Unknown
Yes
SPECIFIC c2use(s) of the SSO:
MJ Severe Natural Condition
❑ Inflow and Infiltration
❑ Vandalism
Longitude(degrees/minute/second)• r
Incident End Dt:�Z d Time•
(mm-dd-yyyy) hh:mm AJP
Estimated Duration (Round to' -nearest hour)-.*—'0�
Z/// r
Volume reaching. surface waters (gallons):L a 0
NoEl Unknown If Yes, what is the estimated number of fish killed?
Grease Roots
El Pump Station Equipment Failure Power outage
El Debris in line / Other (Please explain in Part II)
Imrpediate 24-hour verbal notification reported to: �� ,`//� /r(9i' z1t z '/ �D '/c'm , W
DWQ 0 Emergency Mgmt. Date (mm-dd-yyyy): .. Time (hh:mm AM/PM):
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, acid the discharge could, not have been prevented by the exercise of reasonable control.
Part Il.must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART.II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003 Page 1

Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
PART
ANSWEK I HE t-ULLUMINU t.juta i ivivo rum cH%,H RELATED CAUSE CHECKED IN PART I OF THIS FORM
AND INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIRED OR R,ESIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING TO:THE CAUSE OF THE SSO AS CHECKED IN PART I
In the check boxes below, NA = Not Applicable and NE =:Not Evaluated
A HARDCOPY OF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWQ REGIONAL OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Severe Natural Condition (hurricane, tornado, etc.)
Describe the "severe natural condition" in detail.
How much advance warning did you have and what
T i r
ons. were taken in preparation for the event? /'✓ Z
/.// 1 �./%©,/-: /)/. _ -
Grease (Documentation such as cleaning, inspections, enrorcement
actions, past overflow reports, educational material and distribution date,
etc. should be available upon request.)
When was the last time this specific line (or wet well) was cleaned?
Do you have an enforceable grease ordinance that requires new or retrofit of grease traps/interceptors?
Have there been recent inspections and/or enforcement actions taken on nearby restaurants or other
nonresidential grease contributors?
Explain
I.
❑Yes❑ No DNA ❑NE
❑Yes❑ No❑NA❑NE
Have there been other SSOs or blockages in this area that were also caused by grease? ❑Yes❑ No ❑ NA ❑ NE
When?
If yes, describe them:
Have cleaning and inspections ever been increased at this location? . ❑Yes❑ No ❑ NA ❑ NE
Explain
e
CS-SSO Form October 9, 2003
Page 2

Dut grease been distributed in the past? ❑Yes❑ No ❑NA ❑NE
Explain?
If the SSO occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation?
Were the floats clean?
Comments:
Roots
Do you have an active root control program?
❑Yes❑ No ❑NA ❑NE
x ❑Yes❑ No ❑NA ❑NE
Describe
Have cleaning and inspections ever been increased at this location because of roots? ❑Yes❑ No ❑ NA ❑ NE
Explain:
What corrective actions have been accomplished at the SSO location (and surrounding system if
associated with the SSO)?
What corrective actions are planned at the SSO location to reduce root intrusion?
Has the line been smoke tested or videoed within the past year?. ❑Yes❑ No ❑ NA ❑ NE
If Yes, when?
.Comments:
Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule in any permit that ❑Yes❑ No ❑ NA ❑ NE
addresses 1/1?'
CS-SSO Form October 9, 2003
Page 3

5ctive actions nave peen taKen to reauce or euminate i cc i reiaiea overnows d< «11b bylli lutaUul
last year?
No ❑ NA ❑ NE
i Iaa Ll—� . 11 —I, 11—
If Yes, when was the study completed and what actions did it recommend?
Has the line been smoke tested or videoed within the past year? ❑Yes❑ No ❑ NA ❑ NE
If Yes, when and indicate what actions are necessary and the status of such actions,
Are there 1/1 related projects in your Capital Improvement Plan? ❑Yes❑ No ❑ NA ❑ NE
If Yes, explain:
Have there been any grant or loan applications for I/I reduction projects? ❑Yes❑ No El NA ❑NE
If Yes, explain:
Do you suspect any major sources of inflow or cross connections with storm sewers?
❑ Yes❑ No ❑ NA tl NE
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream been inspected recently? El Yes[] No ❑NA ❑NE
If Yes, explain:
What other corrective actions are planned to prevent future 1/1 related SSOs at this location?
Comments:
Pump Station Equipment Failure (Documentation of testing, records etc.,
shoul be provided upon request.)
What kind of notification/alarm systems are present?
Auto-dialer/telemetry (one-way communication) ❑Yes
CS-SSO Form October 9, 2003
Page 4

way communication)
Emergency Contact Signage
Other
Describe the equipment that failed?
What kind of situations trigger an alarm condition at this station (i.e. pump failure, power failure, high
water, etc.)?
Were notification/alarm systems operable? DYeSO No ❑NA ❑NE
If no, explain: , x
If a pump failed; when was the last maintenance and/or inspection performed?
What specifically was.checked/maintained?
If a valve failed, when was it last exercised?
Were all pumps set to alternate?
Did any pump show above normal run times prior to and during the SSO event?
Were adequate spare parts on hand to fix the equipment (switch, fuse, valve, seal, etc.)?
Was a spare or portable pump immediately available?
If a float problem, when were the floats .last tested? How?
If an auto -dialer or SCADA, when was the system last tested? How?
Comments:
❑ YesO No [INA 11 NE
❑YesO No ❑NA ONE
❑YesO NoElNA11NE
❑YesO No ❑NA ONE
CS-SSO Form October 9, 2003
Page 5

records. etc.. should be.
alternate power or pumping source?
Did it function properly?
Describe?
When was the alternate power or pumping source last tested under load?
If caused by a weather event, how much advance warning did you have and what actions were taken to
prepare for the event?
Comments:
"Yes" No u NA u NE
Vandalism
Provide police report number:
Was the site secured? ❑Yes❑ No ❑ NA ❑NE
If Yes, how?
Have there been previous problems with vandalism at the SSO location? ❑Yes❑ No ❑ NA El NE
If Yes, explain:
What security measures have been put in place to prevent similar occurrences in the future? ❑Yes❑ .No ❑ NA FINE
Comments:
Debris in line (Rocks, sticks, rags and other items not allowed in the
collection system, etc.)
What type of debris has been found in the line?
How could it have gotten there?
Are manholes in the area secure and intact?
❑Yes❑ No❑NA❑NE
CS-SSO Form October 9, 2003 Page 6

ast checkedlcleaned?
ing and inspections ever been increased at this location due to previous problems with debris? ❑YesO No ❑NA ONE
Explain:
Are appropriate educational materials being developed and distributed to prevent future similar 0Yes0 No ❑NA ❑ NE
occurrences?
I
Comments:
Other (Pictures and a police report should be available upon request.)
Describe:
Were adequate equipment and resources available to fix the problem? ❑Yes[] No ❑ NA ❑ NE
If Yes, explain:
If the problem could not be immediately repaired, what actions were taken to lessen the impact of the
SSO?
Comments:
For DWQ Use Only:
DWQ Requested an Additional Written Report: ❑YesO No ❑NA ONE
If Yes, What Additional Information is Needed:
Comments:
CS-SSO Form October 9, 2003 Page 7

Signature: Title:
i
Telephone Number:
Any additional information desired to be submitted should be sent to the appropriate;Division Regional Office within five days of first
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of this form
is completed, if used).
CS-SSO Form October 9, 2003

A ,fie;<�
Form CSR: Collection System Discharge/Overflow Reporting Form
(REQUIRED)
The Reporting form must be submitted to the DWQ Regional Office within five working days of the first
knowledge .of the discharge overflow.
1
Permittee: ut� 0 5 -, h -�i) (A-M (� Facility: Q e-LQAA-,�-,J
Permit Number (WQCS# if active, otherwise use treatment plant NC/WQ#): +4 4Of j
City: ��; (Ali County: 0z'
SPECIFIC location of spi]Vbypass (be consistent in nomencla+-- documentation)
Latitude/Longitude (if available):
First knowledge of incident: (Date/Time)
Incident Ended: (Date/Time): /i Es,
Estimated volume of spill/bypass: 15-6allons. Show rat.
.c:
If spill is ongoing, please notes Regional Office on n .aily basis until spill can be stopped.
-
Reported to: Ke-,4- kA•i.: ❑ DWQ mergency Mgmt. (Date/time) D,
Name of person
Weather conditions: SQ-✓ z) e
Source of spill/bypass (check one): Sanitary Sewer Pump/Station WWTP
Level of treatment (check one): one Primary Treatment Ej Secondary Treatment Disinfection Only
Did spill/bypass reach surface waters? ❑ Yes �oP (If Yes, please answer the following)
Volume reaching surface waters? gallons
Name of surface water l� or' 7—o� k' /—
Did spill/bypass result in a fish kill? 0 Yes I-90--
If Yes, what is the estimated number of fish. killed?
SPECIFIC cause of spill/bypass:
Severe Natural Condition
Inflow and Infiltration
Grease
❑ Vandalism
❑ Debris in line
Roots
❑ Equipment failure
Power outage
Other uncommon event
Explain:
pu. , r �A)J
H
EcC �yE
SEP - 7 2004 0
WATER QUALITY SECTION
ASHEVILLE REGIONAL OFFICE
I certify that the information contained in this report is true and accurate to the best of my ,knowledge.
Person submitting report: Date:
\�
Signature: � V
( ✓ )

W A�tF�9oG
Form CSJ: Collection Si
tem Discharge/Overflow Justification Claim Fo
The Director, Division of Water Quality, will take enforcement action for sanitary sewer system
discharges that required to be reported to the Division unless it is demonstrated that:
(1) a discharge was caused by severe natural conditions and there were no feasible alternatives to the
ddischarge;
or
(2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable
control of the Permittee and/or owner, and the discharge could not have been prevented by the exercise of
reasonable control.
This form may be used to demonstrate (I) or (2) above. This claim form and'appropriate attachments should be
submitted to the Regional Office along with the Reporting Form within 5 working days of the date of the first
knowledge of the discharge/overflow in order to be considered for immunity from enforcement action by the
Division.
Permittee: Permit Number.
First knowledge of incident: (Date/Time) /
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN THE CSR FORM AND
INCLUDE THE APPROPRIATE DOCUMENT T A T ION
Severe Natural Condition ( 24hr/25yr storm, hurricane, tornado, etc.)
Describe the "severe natural condition" in detail.
Has this condition occurred in this area before? Ej Yes No If Yes, when?
Comments:
Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule in your permit that addresses I&I?EJ
`Yes'' I*Io:; ri . ;
" ; Explam if
What corrective actions have been accomplisl ed that are associated with the spill location within the last year?
�s
What corrective actions•are planned to prevent future spills at this location?
Has the line been smoked or videoed within the past year? 0 Yes No If Yes, when?
Comments:
DRAFT CSJ Form Mav 23- 2003 DRAFT

09: 03
7332069
NEWLY' ND
PAGE 01
4�
Y
Form CSR: Collection System Discharge/Overflow Reporting Form
(REQUIRED)
The Reporting form must be submitted to the DWQ Regional Office wilbin f Fve wnrklM of thefirst
knowledge of the dischargel/overfl�ogw. N
Perrnittee: f � a t i'J?'(j N Facility: Oe-4P .1
Permit Number (WQCS# if active~ otherwise use treatment plant NC/WQ#): S +4 40/U
[} N 22
op 2f f 7
City: eu. (Am
Am O! County: Or—,
SP)ECEFIIC location of spill/bypass (be consistent iu nomenclature from past reports or documentation):
Latitude/Longitude(available): � 5`r
if--,figjrr
First knowledge of incident: (D`aterrime) / p'z — S q
Incident Ended: (Darerrime): /i .., -irk Estimated Duration
Estimated volume of spill/bypass: 1 allonc Show rational far volume:
if .Fpill is ofrgnm'gr please notify Regional Offiee on a daily basis until spill car be stopped.
Reported to: K r`+'L. I--A.a!� ❑ DWQ rnernency Ma nt (Date/time) , �p A
Name of person /
Weather conditions: Se.vitrre- -Y
Source of spilllbypass (check one): ❑ Sanitary Sewer prg station [] WWTP
Level of treatment (check one): ane J Primary Treatment 0 Secondary Treatment ❑ Disinfection only
Did spilUbypass reach surface waters? ❑ Yes (If Yes, please answer the following)
Volume reaching surface waters? gallons
Name of surface water
Did spill/bypass result in a fish kill? ❑ 'Yes
if Yes, what is the estimated number of fish stilled?
SPECMC cause of spill/bypass-
Condition
❑ Roots
❑ Inflow and infiltration
❑ Grease
❑ Vandalism
0 Debris in line
Equipment failure
❑ Power outage
❑ Other uncommon event
Explain;
I certify that the informaflon contained in this report Is true and accurate to the best of my knowledge.
Person submitting report: Date:
r+ti a x"r VQV Timm M2ki l ?nna nv x Wr
E V E
U
E—S 2 2004
WATER QUALITY SECTION

RD E c E � v E D
SEP 1 0 2004 0
Phm: I WATER
Fmi
Tel KOM Haynes NC DENR Flocs DoW SmM
Dodm SeprWdw 10,2004
phor : p"low 9
NO OIImM W RGOW FerM CO
0 NblrM O rw Rrdow ❑ err ftnwm t VPMMO RMW 0 Mw" Mmyda
-Common" Hl rA tl
If you hm* any questions OW mb s colt
Garold

WATER QUALITY SECTION
Form CS-S60
Collection System Sanitary 80"r Overflow Repcdng Form
PART I
Tide form Shall be submitted to fhe appWriate DWQ kegionw Onjw wftlxn five daysof the itrat knowledge W
the sanitary cotter wier>low (330).
Ponvin Mumder : NC 321 (yyQp ffacwo, o"Mmise use traebmnt talent NCIW Q#)
TMM0f M ilbWWrP ktcklant 1
owner Tom (XW"nnywo
Soww of M (avok appl'*") : ❑ sanitary sewer ❑ PMV Matim
a
WNC
Counly: N*Y*O t
SPECIFIC kmt$on of Via SSO (be count In dosorlpdon from prat nva is or dommwrdlion - La. Pump sudlon 8,
tMlw tl * at WOMI a &am Street. etc.): f"M" M""" , 1 14,1 00`"tV*AWVWWTMQbld n Pkwt
f, 01hide (dagreeWminoWsoc d): L0h0 tt *dbpnbes/mftk WhacMd)'
hVI(Wat fat: 0"7 2M 10:00 pm Mldderlt End Dt22:29t=4 T .t 1130 am
taut d o-YYYY) t++Lm9n em AM (UNWO yypf} hb..-m A1wPM
EX""teal VvkM + or #ra SStr - W palkxw Eslknalad Dufulloh (kcwnd to nearest twat 3�---
Deedibehow the voium vmdsten*wd: r�+w+aa�a�n.ar.raaae
W016W canrYtinna Amirg Sao WM* *Ood --d
pkl S3U reach aurtace walera7 E1 YemE]hlo❑ tlttiurowwn Volume rea&&Q aurface waters (gauo x): NAM
$rsWe wafer cmm., Maw P!
0M the SSO t Ina tibh kilt? ❑ Yaws Q No ❑ lfftVKrwwra ff Yes, wn i# ties �alaurrtrtad nurnn,vr of lhlh fcitf f9
SPECIFIC cause(s) of fhb SW:
Savant taop W Caption ❑� £i &Is& ElRnota
1� Intiow and witbaflon 11 pwv station Ewowt Fvjwm 0 P w.r outage
Vandalism c) Detxw in tine ❑ otw (Please avtam in Part II)
ktartadiMe 2"w verbal noWcadan reported to: I"MM
Elam El EnWq"%ey UAgrrot. Data ( YYIAr): 09.4>9.2004 , Time (hh:mm AI6M3,1 t: iom am
ff an 550 is ongoing, please notify Regional Office on a daily basis until $SO can lie stopped.
last G.S. 113 151 G(b), the ra�poraaaala of a disdorge of 1,000 galkma or more of untreated wastewater to sw(ace
waters straw iesaab a prods release �ritYdi�tl0ura 4f fir$t knowledge 14 all {nitst and electronic rsews rrwda providctq pererai
oaaeraga in the aoaur+d. When 1SAM gallorm or more of untreated wastewater entem awfam
waters, ar VuW rK" char to pubWied *Mn 10 dap and proof of publicafiah ahel be provided to the E*Asion w Mrt 30 days.
PkAw to the Ys*or*d *Mr,da for Affftrsr defall.
Thrt Clk*Our. I)IvWm of Water Quality. may take enfartaement s0" tar Me VW am nK ukad to be moorled to Dhridon unkm it
1) ftm dfaotwrgo was caused by aevere natural cmOms and IN" Woe no &aibOm sllsmatives to the or
2) the dbdwvgs was ex opti"I. unlr"AOXW, k wvorsiy grad by hctord beyond the reaeorr Me W061 d the Pemr>efoe
aaWw owner, and the dWh&V coW not have been prevented by the exbrdae of renexa tM confral.
Pad li mart be oxn pbfad to prnNda a jaadlflaafion cialm for either ul the WxNo al uedons. This kdamaWn wH be the baWa
fortrio dvWmIrWjon of any onfUrowwK ixftn. Th®ref m, @ Is bVorlarrt to tw as ae porelbia.
WHETHER OR NOV PART If IS COWLETED. A SIGNATURE f$ REQ UIRIM AT THE END OF THIS FORM.
Ca4W Fo" Ootd er 9. 2003 Page 1

rt�rr.
Form cs_sso
Collection S�1stm Sanitary Server Overflow Repordrng Fmm
PART I I
ANSWM THE FOI.LOYANG QUESTKWS FOR EACH RELATED CAUSE CHEc.Mo W PART t OF THIS FoRm
AND INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIREV OR VFZRW
COMPLETE ONLY THOSE SECTIONS PERTAINING TO THE CAUSE OF THE SW AS CHECKED IN PART 1
In the chogc bome mow. NA - Not AppBouble end NE - Not Evaluated
A HARDCOPY OF THIS FORM $MOULD IE SUOMMM TO THE AP'PROpRIATg DWQ REGICML OFFICE
UNLESS R HAS BEEN SUBMI11 ELECTRONICALLY THROUGH THE ONLINE REPORTING; SYSTEM
Severe Natural 92mon,(hurricane. boff►ado, etr
Oeiaatb* itrr -aaYtpre traaurq aor,tpdoM in dell,
Floodit causW by Humcans 1 Tropical Storm Frances
How nxx h adv*ms warning did you tmie end what acdms two idlw in preparmUm far tfm event?
1 2 days
Carrunwds:
Cvaeow dun b todtop�ood lay.ra m Tawn 01 Cdytr, a.luai�+lli* �Y 46skld oaMr coNaodon �►. At.o Nagdty pbq i40wrbp �rsnNt �IN.P� away
c&& n wa wulca km svxhagft Uolwao m Road i R(wrbwm Samwmaw lice. an Tyr Ymm Or Wepwalb cobd6n ayMwn
was the last llmrt Via apeeft tlfw (or wot w") rrae dwshW
Do you haws On erdbm dhte yroare ordinranoe dW ffigAms tww or mboflt oI gnrr+ae trapeJir wmODW ©YX too O" EINE
Have there bean recent ingpapdorm anQlor enfpPoernertt actions taken on nearby reau"W to ar caw ❑r..0 m ❑ire .,. we
nareeadarMW Weaan cmO~
Hmm thme tmm other SSM or bbdmgw In 0* aw OM wore also aamd by gmm? Y rro m Ns
If yen, dwabo them:
tines clenrrk and hrapatfim war barn i - gang at t ft taaetlm? No 0=
CS SW Form WOW 0. 2bll$ P846 2

E Oftd
soot a mawo UWJ
m omma"Ps
M[_j VmE)a:J j]rAj3 lmt *umd Au m U{ "M*Ww s *A*4 A" ONo (wvow0 iW Apio lopft) oM umAPB rn( &w
+" Pug Wpq
~ 109A A
3NQ VNQ oN cro I &qmA pw W4 mmm PODWA jo Pol UO" OUR ma Wi
emu! 3m mww atvap"q ORR OA W POULMO we a mp= w[lxww w 1iUl
dose eta tw P
UMQ t BUltWM PM) UROM OCR Ma W PUPOMOM iROR GAM4 MMM GAPUM P W
mci VNu eN ME) btpm p aww-m4 LR*io1 W 1Q poumwtM ubeq Ws 6"lu PUB f4us+Nla WJH
2NE]VNQaN QWAO
3iQYNQaN [rA(]
VPJftld P4UOO JOW GAP= Us aNs4 noA oa
bump OWN 04 •oM
Lufpnmwm*
amkz A4 Pmpnp pm sdund Pw lip pa ma sex► MVA lugw a dUW4 s in Pamob b Ogg ma A
aupidmal
&wow W PM
3140VNOC" x0 as*d *4 u! Pqn*jmP LMQ "Ofto row mwspw mu*mxw eM:

If Yes:
mwc oomecUye actlons hem been t *An to t+ch,o. ar e�rni►auis 1 �, satated v+►esflvwa st thls apilr Ioieatlon
arMhiss the tad yawsl
lie. them been any flow sa,dte. to driterrriina Ui iprobta�nr In the CoilstfiGn f�yatenl at the aso tecation? Y Na M
If Yee, When WM 4at abidy Cos Wkft t and wtM aati M did it moommend?
Rothe Nne been amoke tested or vldeowd within flu pwA yein? OYMOMOttE
If yft ~ and kwkato udw sca" aye necessary and the *lot e d eadi eetiona:
Are dwrs Ill relaesd prnjecte In Vow Cep4W Imppvernsm Plan? Y w NA FVE
# Yea, sxpialn:
time e them been e11y yrerit or Wn appilcau m for tll rodutjan polvft? UYAAJ t to UNA LJNE
If Yes. eeo)w:
04 you +usp O any msjnr muro* of Intlaw or onma o wmtlons with abm severe? MX Nu El;lNE
I(Ya, dxplaln:
Have all fkms owdacling surface wa*m In the = lociom and upstream been impeded reasntfy't Y t—Z 18A NE,
If Ye6 �
What ottMK ounective scgwm une planr>od to powAK t fishue in reiaW $SN at tb* kwAkol
(7astrtlerr3e:
Pro
Au*dWe►Jt Wanly (mw way earnrnsasieation) Oven
C9480FOrm Otto W 9. 2W3 P"s 4

AudNe Y..
vwiw Y.
SCADA (two-way CDWMhrdWtlQn)
Emwgwncy Conbid3 a
01tw
DewUjftN*equipmerttt►ltitf %Q?
What kind o(plumtkm biW all alafln ton NW at this StOlk n (l.e. PUMP lWkKD, Pms %ihme, hO
vmw, aft.)?
Wale na hVomO=VWw i syelefi op*tWG7 ; lE
tt p tramp Tsl w. wtibn vms #m met ma$tonOtlon mwdlw h►sl AC*m pm(OrRltld?
What eped&*fy wu dedwdhrw)nWnW?
jr a vow faded whbn wee it km ame dmd?
Wing ail Pumps agt to Oftfr ste7 Elymc
Did any pump *Nor above n urtid run tknes prior t0 and drakld the 9SQ rm*7 OvIG NIGH 13tE
Hvero adoquate apme pufttt on hand is in the pquOTHN t (awit4h, ftw, vattla, awl, eto.)7 LJYeaL..r W ON A IINE
Uwe a spore or p orbbb puny lfnlnadA i* SVWWW Oven NO CINA D E
K e float probbmk when warty the Abaft last fleeted?
if sn mAD d star or SCAEK whsn was Alto sysmn lmd iNWV Hm?
Cenmellb:
A S-M Fwm Ock bar O, 2W3 Pop 5

b
i
J
I
I
$ 1$
a

.4 gftd
�(�vpf"'tont�•1t�'f
soot `$ O uWA 088 97
Msp""*l MmLgwpv~w*A
4AdM UMM WJCOI SN as P 2i DAM
: up wi bow
LOB
Ui1Q V*Jq No UM f at tMM a" win= iKW Va*gdw AWAMOUN4 +a IOU ow UMMM OWA
WAX
3N©MLIM +.AEI tub wit xga appv� skumo ou ptw xo m*fim it F P ejem
1
IpmumopfimpowmOmmommumvA

Asa MMVhdWo for the nkgmnaVa poft, t ooffify tha# the infarmstion tairtad in this repM is bve pnd accurate
to t! M best of my .knwa edge.
Panson inn claim: Qa v c d 5,41 %7` ff
tom: q1t`,1,2 ooq
t t r
TIM
%lepftotte Numtwr
Any additkM inftma*m dgshad to be a0mtaod shouts be eerd to the MpVpd&W Diviwan R Oft$ *Wdn NO 42P of brat
krtowbdge of the $SO with rofarome t o the htickWd number (ths MddeN numtrer Is mly gwwoW when aWctrordc entry of this farm
b oampwwL it u604p.
CS4M Form Odutor 9, 2003 Pao $

X
WATER QUALITY SECTION
I
Form CS-SSO
Reporting Form
PART I
This form shall he submitted to the appropriate DWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number: G5 Ode (V CS# if active, otherwise use treatment plant NC/WQ#)
Facllily: `� V r ` Incident 1V
u Re ion:
owner: 5
City: e County: —T— --- -
Source of SSb (check applicable) : A Sanitary Sewer 0 Pump Station
SPECIFIC location of the S-90 (be consistent in description from past reports or documentation - I.e. Pump Station 6,
Manhole at Weslall & Bragg Street, etc.) : Camal ert DF. - - —
Latitude (degreesiminute/second):
Incident Started Dt: 9 ��o� Time,
(Mrn-W-yyyy) hh:mm AM/PM
Estimated volumo of tho SSO: U b ErI eu+Yt gallons
Doscribo how the volume wins dutormined:
Longilude(degreesfminuWsecond)
Incident End Di: ¢—� �� Time ?• *2
(mm-dd-yyyy) hh:mm AMlPM
Estimated Duration (Round to nearest hour): 04 42S -
Wcathor conditions during SSO event: Dt— r'w �� a !$ go", d faU,t r9
Did SSO reach surface waters? 9 Yos ❑No ❑ Unknown Volume ronching surface waters (gallons): tyri J;,, et,- yti
Surface water name: CC M 42 R 8 An G k
Did the SSO result in a fish kilt? ❑ Yes oNo ❑ Unknown If Yos, what is tho estimated number of fish killed? — -- - -
SPFCfFIG causo(s) of the SSO;
Severe Natural Condition ❑ Groase 0 Roots
❑ Inflow and Infiltration ❑ Pump Station Equipment Faituro ❑ Power outago
❑ Vandalism ❑ Debris in lino ❑ Other (Please explain In Part 11)
lmmodiate 24-haurvorbal notification reporlod to:
`� DWQ M Emergency Mgmt. Date (mm-dd-yyyy):!9.-47-e7y Time {hh:mm AMIPM): ff: ad r}r+t
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsibte party of a discharge W 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county w erg a the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall bo provided to the Division wfthln 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quallty,may take enforcemenl.action for SSOs that are required to be reported to Division unless it
Is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permlttee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part 11 must be completed to provide a Justification claim for either of the above silt}ations. This Information will be the basis
for the determination of any enforcement action. Therefore, it Is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REOUIREJ AT THE END OF THIS I=ORM,
GS-SSQ FOrM October 9, 2003 PaI$e 1

1
V
Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN PART I OF THIS FORM
ANO INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING TO THE CAUSE OF THE SSOAS CHECKED IN PART 1
In the check boxes below, NA = Not Applicable and NE = Not Evaluated
A HARDCOPY OF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWQ REGIONAL OFFICE
UNLESS !T HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Severe Natural Condition (hurricane, tornado. etc.
Describe the "severe natural condition" in /detail.[ /� q� n 1
i�'e. ke C. e""'4l Rlroywf it O RQ,r •� -PXaM 1-'2 If A{J 3'�.�1 �•$'�a4 P^
How much advance warning did you have and what actions were taken in preparation for the event?
Comments;
Grease (Documentation such as cleaning. insoections. enforcement
was
woll) was cloanod?
Do you have an enrorceablo greaso ordinance that requires new or retrofit of grease trapslintorcoptors?
Have there boon recent Inspections and/or enforcement actions taken on nearby restaurants or other
nonresidential grease contributors?
Explain.
Have there been other SSOs or blockages In this area that were also caused by grease?
When?
If yes, describe them:
D YosO N4 D NA U NE
LJ Y9�O Na ❑ NA © NE
❑Ye0 No DNA ❑NE
Have cleaning and Inspections ever been increased at this location? ❑YesO No ❑NA ONE
Explain.
C$-$SO Form October 0, 2003
Page 2

as the area last checked/cleaned?
Have cleaning and Inspections over been Increased at this location due to previous problems wiih debris? ❑Yes❑ No ❑NA ❑NE
Explain:
Are appropriate educational materials being dev©loped and.disiributed to ptevant future similar © Yes❑ Na ❑NA ❑NI=
occurrenees?
Comments:
Other (Pictures and a police report should be available upon request.)
Describe:
Were adoquate equipment and resources available to Cx the problem? ❑Yes❑ No ❑NA ❑NE
It Yes, explain:
it the probiom could not bo immodiatoly repaired, what actions were taken to lossen the impael of thu
SSO?
Comments: JJ Jj
For DWQ Use Only:
OWQ Requostod an Additional Written Report:
It Yes, What Additional Information Is Needed:
CUmrnents:
❑ Yos❑ No ❑NA ONE
C5-8So Form October 9, 2003
• Porra 7

,o for the responsible PaLty, I cartit thal the information contained in this report is true and accurate
to the best of my xnowlOd e.
Person submitting C1alm: 01"4 f a rd " 12- K Date: a y
Signeiure: Title: '*+,
B R c W914ZA a 5e— rL P'V"
Telephone NuMber: $;2�
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five days of first
knowledge of the SSO with reference to ttte incident number (the incident number is only generaled when electronic entry or this form
is completed, if usod).
Page
CS-SSO Form October 9, 2003 6

91 E � Y_ E
SEP - g 2004 0
G
7
r
Y
Form CS -SS(
Overflow Reporting Forn
PART I
This form shall be submitted to the appropriate DWq Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number. 000, WQGS it active, otherwise use treatment plant NC/VV.04t)
Facility: °i r ' Incident A
O
l7wner. Region:
city: County: cc
Source of ,SSO (chock applicable) . A Sanitary Sewer © Pump Station
SPECIFIC location of the SSO (be consistent In description from past re arts or documentation - I.e. pump Station S.
Manhole at Westall A laragg Street, BIG.} ; Gik
Latitude (degrees/minum/second):
Incident Started Dt:
(---dd-yyyy)
Time --A -'06 Apt
hNmm ANVPM
Estimated volume of the SSO: -VJnX ► Wf(A gallons
Describo haw 1110 volume was doleemined;
Longitude(degreoWnilnute/second)•— . .�e_�,.
Incident End Of; y Time:� ,,.,,.,,,,
(mrn�dd-yyyy) hh:mm AM/PM
Estimated Duralion (Round to nearest hour): -
Weather conditions during SSO event: er t
Old SSO reach surraco wators? T% Yes CJNo C3Unknown Volume reaching surfaco waters (gallons):yn jCrt16r►,*,'
Surface water name: - C1M,p 9 Mn cA
Did the SSU result in a fish kill? ❑ Yes %o ❑ Unknown If Yes, what Is Mo estimatad number of fish kiflod?
SPECIFIC C use of the SSO;
Sovero Nalural Condition
IJ Inflow and Infiltration
© Vandalism
Immediate 24-hour verbal notifiied6un reported to:
MDWO = Emergency Mgrnt.
Q Grease 0 (fools
Pump Station Equipment Fatlure 11 Power outago
Debris In lino Other (Please explain In Part II)
d:
Date (mm-dd-yyyy):_-'? rime (hh:mm AM/PM):P, 00 ,+$
If an SSO is ongoing. please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215,1C(b), the responsible party of a discharge of 1,0(* gallons or more of untreated wastewater to surface
waters shall issue a praaswease within 48-hours of first knowledge to all print and electronic news media providing general
coverage In the county w erh re thadischarge occurred. Whpn 15,000 gallons or mere of untreated wastewater enters surface
waters, a public nonce shall be published within 10 dayfi and proof of pubtiration shall be providep to the Division within 30 days.
Refer to the referenced statute for further detail_
of Water
to be
1) the discharge was caused by severe natural Onditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintention�a!`temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not ha / a been prevented by the exercise of reasonable control.
Part It must be completed to provide a Justfr atloa claim for either of the above situations. This information will be the basis
for the determination of any onforaement Ilion. Therefore, It is important to be as complete as possible.
WHETHER OR NOT PART II IS C( JAPLETED, A SIGNATURE IS REQUIR50 AT THE END OF THIS FORM.
C"SO Form October 9, 2003
Page 1

G4lfection System Sanitary Sewer Overa Reporting
ANSIJ+✓ t=orrri CS-SSC
N�'` TH FOLLOWING QLE I ��ffrr C rung Forn
NJACTHE V+IoNS FOREACH RELATED CAUSE CHECKED W PARTI OF THIS 'qAPPROPRIATE DOCUMENTATION AS REQUIRED OR DESIRED FORM
COMPLETE ONLY THOSE SECTIOhIS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN PART I
In the check boxes below, NA = Not Applicable and NE = Not Evaluated
A HARDCOPY Of; THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWQ REGIONAL, OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Severe Natural Cond�rricane, tornadta, etc.
Descdbo the "severe nalurar condition" in delail.
v 1' '-OK uy f�' - o y
How much advance warning did you have and what actions ware taken in preparation for trio event?
Comments:
Wttgrt was the last lirile Ibis SpocEffc lino (Or wet well) was cloanco
Do you have an onfarcoablo groaso ordinance that requires now or rotrofit of groaso trapslintorcepiuW pYOs❑ No [DNA ❑NE
Have there boon rocant inspections andtar enforcement aclions taken on nearby restaurants or other n❑Yo,O No ❑rJA ©N�
onrosidontial groaso conirlbutors7
Explain.
Have there been other SSOs or blockages In this area that were also caused by grease? QYes❑ No E lNA ❑NE
When?
If yes, describe them;
Have cleaning and Inspections ever been Increased at tfirs location? ❑YosU No ❑NA LINE
Explain,
CS-SSO Form October 9, 2003
Page 2

When was tha area last checkedlctoaned?
Have cleaning and Inspections evar been increased at this location due to previous problems with dahris? ❑Yes❑ No tJNA ❑NE
f'✓xplaln; 1�I rr�-� Are appropriate educational materials being developed and distributed to prevent future similar ❑Yes+-- too ❑NA ONF-
occurrences?
Comments;
Other (Pictures and a police report should be available upon request.)
Describe:
Were adoqu ite equipment and resources available to fix the problem? ❑Yea] No ❑trA ❑NE
If Yes, explain
If rho protAont could not ba immediately repaired, what actions wero taken to IOS50n tho Impact of um
5507
Comments:
/ u a� 5+3
For QWQ Use Only;
DWQ Requested an Additional Wrilton Report:
If Yas, What Additional Information is Nooded:
Comments:
O Yes❑ No IJ NA ❑ NE
CS-SSO Form October 9, 2003 panty 7

resentative for the responsible party, 1 Certify that the information contained in this report is true and accurate
ILP u IC u8st of my Knowledge. /1 J
Person submitting claim: Vj`e." -p-q rd Le-e- �l'eDate:
Signature: l e o � �`"_, Title: L:— fft'y- Ct?---�-
aR VA4,-&
S�wEc�t. p�jvt
Telephone Number:
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five days of first
knowledge of the SSO with reference to the Incident number (the incident number is only generated whon olectronic entry of this form
is completed, if used).
CS-SSO Fonn October 9, 2003 -
Page 8

p L E ---
� D
S EP - g 2004
WATER QUALITY SECTION
ASHEVILLE REGIONAL OFFICE
Form OS -SS(;
Collection System Sanitary Sewer Overflow Reporting Font
PART I
This form shall be submitted to the appropriate DWO regional Office within Five da s of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number: Wo5a
(WGICS# if active, otherwise use treatment plant NG/WCitl)
Facility; 6 a tit
Incident #
Owner: P (/
Region:
City: e - -`
County;
Source or sso (check applicable) : Sanitary Sewer ❑ Pump Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation - Le. Pump Station 6,
Manhole at VVestall & Bragg Street, etc.): _ t R re fi 14a+04-4.
Latitude (degraeslminute/second): Longitude(degreeslrninute/second)'
lncidunt Startad tat: — ^Q'4 Time: ' ory A& Incident End Dl:_�--1- 6 LI
(--dd-yyyy) hh:nun A11 t1PM Tlme'
(MrTMdd'yyy'y) hh;mm AM1PM
Estimated volume of Itua 580: gallons Estimated Ouration (Round to nearest
Describo how the voluma w;13 doldrntined:
Weather conditions during $So event: Vat-i 14tad4 R<r: rt 41r'6,361a e R4�
Oid SSO reach surfaco waters? 4-Yos ❑No ❑ Unknown Volume roaching surface waters (gallons): �A
Suffaco water name: Sew Kna ""
Did tho SSO rosull In a fish kill? Q Yus f3NO❑ Unknown If Yas, what is the estimated numbor of fish kiflod7
SPECIFIC causo(s) of the SSo:
LAF Sovaro NMLIMl Condition ❑ Greaso ❑ Roots
❑ Inflow and Infiltration ❑ Pump Station Equipment Failuro PowCr oukngO
© Vandalism 0 Debris in line ❑ Other (Please explain in Part It)
Immodlato 24-four verbal notification reported to: . %*
DWCt = Emergency Mgmt, Date (rnm,dd-yyyy): Q- 9 r7a Time (hh:mrn AM/PMI: St►aa A.,,
If an SSo is ongoing, please notify Regional Office on a daily basis until SSO can be stopped,
Per G.S, 143-215.1 C(b), the responsible party of a discharge of 1.000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the County w eri —the the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a publio notice shall be published within 10 days and proof of p0lioalion shalt be provided to the Division within 3(1 days.
Refer to the referenced slatule for further detail.
The Director, Division of Water Qualit , ma take enforcement action for $505 that are required to be reported to Division unless it
�Qmpnstrated that:
1) the discharge was Caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporafy and caused by factors beyond the reasonable control of the Permlttee
andlor owner, and the discharge Gould not have been prevented by the exercise of reasonable control,
Part 11 must be completed to provide a lustiticatlon claim for either of the above situations_ This Infonration will be llle basis
f(;r the determination of any enforcement action. Therefore, It is important to be as complete as possible,
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS RrMUIRED AT THE ENE) OF THIS FORM.
G5-SSO Form October 9, 2003 Pans 1
V

Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
PART I I
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN PART t OF THIS FORM
AND INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN PART I
In the check boxes below, NA = Not Applicable and NE = Not Evaluated
A HARDCOPY OF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWO REGIONAL OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Severe Natural Condition 1hurricane, tornado, etc.
Describe the "severe natural condition- In detail.
t- - ctr'byn d( if" o I- lirL r, !^'! o++� $- %—at#.. Pn. u_ nf: How much advance warning did you have and what actions were taken In preparation for the event? �.
Comments;
actionspast overflow re orts educational material ant
etc. should be available upon request,)
Whon was tho last limo thls specific lino (or wet woir) was eloanod?
Do you have an onforcoable groaso ordinance that requires new or rotrolit of groaso Irapsfintorceptors? 1:1Yi4 No ❑NA ONE
Have thorn boon rocont inspections andlor enforcement actions taken on nearby restaurants or other 1-1Yes0 No ❑NA ❑NE
nonresidvnilal grease conlrtbutors?
Explain.
Have thorn been other SSOs or blockages In this area that were also caused by grease? ❑Ys.0 No DNA LINE
When?
If yes, describe thorn:
Have cleaning and inspections ever been Inweased at this location? ❑Yes] NX)NA©NE
Explain.
CS-SSO Form October 9. 2003 page 2

area last chocked/cleaned?
9nd inspections ever been increased at this location due to previous problem$ with debris? ❑ Ye0 No ❑NA ❑NE
Explain:
Are apprppriate educational materials being developed and distributed to prevent future similar ❑ Y,,.0 No ❑IVA ONE
occurrences?
Comments:
Other (Pictures and a police report should, be available upon request_)
Describe,,
Were adequate equipment and resources available to fix the problem? ❑Yes❑ No ❑NA DNE
If Yes, explain:
If tho problem could not bo imRtodi'Uely roppirgd, whit actions wore taken to lesson tho I111p:1ct or ttw
SSO?
Comf mmonts, / J -1 1 1 r ,y /�
v L ._ 1�1a' GI T6 1-i� i 1 Li �'t I'. f M. L N � 7
For DWQ Use Onl
DWG! Roquestod an Addi(ionoi Written Roport: ❑Yesu Na [ INA ONE
If Yes. What Additional Information Is Nooded:
Communis:
CS -$SO Form October 9, 2003
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