WQCS00221_Regional Office Historical File Pre 2018

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#
-12 t
Incident Number from BIMS
Incident Reviewed (Date):
Incident Action Taken: BPJ
Spill Date GU O
Reported Date
NOV-2008-DV
Time Z_ am p
Time m pm
Reported To SWP Staff or EM Staff 60
Reporte
Address
County
Cause c
Total EE
Stream
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad
�V

Permit #
Owner and Facility Name
WQCS00253
Bradfield Farms Water Company CS
WQCS00196
Carolina Water Service Cabarrus Woods CS
WQCS00233
Carolina Water Service Hemby Acres CS
WQCS00001
Charlotte -Mecklenburg CS
WQCS00016
City of Albemarle CS
WQCS00046
City of Belmont CS
WOCS00107
City of Bessemer City CS
WQCS00089
City of Cherryville CS
WQCS00221
City of Claremont CS
WQCS00326
City of Concord CS
WQCS00088
City of Conover CS
WQCS00017
City of Gastonia CS
WQCS00020
City of Hickory CS
WQCS00327
City of Kannapolis CS
WQCS00036
City of Kings Mountain CS
WQCS00040
City of Lincolnton CS
WQCS00164
City of Lowell CS
WQCS00026
City of Monroe CS
WQCS00059
City of Mount Holly CS
WQCS00044
City of Newton CS
WQCS00019
City of Salisbury CS
WQCS00037
City of Shelby CS
WQCS00030
City of SFatesville CS
WQCS00149
East Lincoln CS
Deemed Permitted
Permit #
Owner and Facility Name
WQCSDO130
Brooks Food Group -Brooks Food Group
WQCSD0114
Charlotte Mecklenburg Schools - Misc Laterals
WQCSDO057
City of High Shoals CS
WQCSD0117
Duke Energy Marshall Steam Station
WQCSD0257
Fallston
WQCSDO116
Goose Creek Utilities Fairfield Plantation WWTP
WQCSDO101
Harborside Dev LLC-Midtown T CS
WOCSDO095
Kennerly Dev. Group LLC-Boardwalk Villas CS
WQCSDO098
Kennerly Dev. Group LLC-Kings Point CS
WQCSDO105
Kennerly Dev. Group LLC-Moon Bay Condos CS
WQCSDO107
Kennerly Dev. Group LLC-Schooner Bay CS
WQCSDO099
Kennerly Dev. Group LLC-Spinnaker Point CS
WQCSD0258
Kingstown
WQCSDO 112
Lake Norman -South Point CS
WOCSDO104
'-ake Norman -Villas S Harbour CS
WQCSDO102
Lake Norman -Vineyard Pt Resort CS.
Permit #
Owner and Facility Name
WQCS00171
Greater Badin CS
WQCS00322
Aqua Country Woods East CS
WQCS00222
Town of Boiling Springs CS
WQCS00341
Town of China Grove CS
WQCS00231
Town of Cleveland CS
WQCS00058
Town of Cramerton CS
WQCS00165
Town of Dallas CS
WQCS00342
Town of E. Spencer CS
WQCS00328
Town of Harrisburg CS
WQCS00343
Town of Landis CS
WQCS00310
Town of Longview CS
WQCS00120
Town of Maiden CS
WQCS00344
Town of Marshville CS
WQCS00043
Town of Mooresville CS
WQCS00125
Town of Mt Pleasant CS
WQCS00153
Town of Norwood CS
WQCS00190
Town of Oakboro CS
WQCS00325
Town of Stanfield CS
WQCS00180
Town of Stanley CS
WQCS00135
Town of Taylorsville CS
WQCS00258
Town of Troutman CS
WQCS00345
Town of Wingate CS
WQCS00054
Union County CS
WQCS00009
WSA Cabarrus Co. CS
Permit #
Owner and Facility Name
WQCSDOG64
Lincoln County CS
WQCSDO097
Martin Dev Gp-N Point & Porlside CS
WQCSD0120
Martin Marietta Mallard Creek
WQCSDO019
Town of Richfield CS
WQCSDO024
Town of Grover CS
WQCSDO038
Town of McAdenville CS
WQCSD00.02
Town of Ranlo CS
WQCSDOQ49
Town of Spencer Mountain CS
WQCSD0252 All spills which do not have a permit
number assigned

10/24/2008 16:07 FAX [phone]
[A 001/022
PA -
` North Carolina
Fmax
To: DCn na
Fax:
Rhona:
Re:
Aqua North Carolina, Inc.
4163 Sinclair Street
Denver, NC 29027
From:
Pages:
Date: j �^
CC:
F: 704.499.9409
vvww,aqua nornccarol ina.com
❑ Urgent Zi or Revlew ❑ Please Cornnnent C] Please Reply 0Please Recycle
i y
An Aqua America Company

10/24/2008 16:08 FAX [phone] IA 002/022
Ar$,� Form CS-SSD
P
7r Collection System Sanitary Sewer Overflow Reporting Form
�i 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 (S80
1)._
Permit Number: N OUP ��' , (WQCs# If active, otherwise use WQCSD#) W�%i OO i �t71�5
Facility: J WW P Incident#
-Region
agion:R_C.}rJOwner: County: c
city; Source of SSO (check applicable) : U30"Sanitary Sewer ❑ pump Station I Litt Station
SPECIFIC location of the SSO (be consistent in description from p�a�st ports or documeiozj i tation - e.. Pump Station 5r Coun+Puf ,
Manhole at Wastell & Bragg Street, etc.) : —�
Manhole#
Latitude (degrees/minute/Second):
Incident Started Dt: 1012010 A Time, '
(mm-dd-yyyy) hh:mm M
Estimated volume of the $SO: 4 q 40 gallons
Describe how the volume was determined:
Weather conditions during SSO ev- n"
Did SSO reach Surface waters? U Yes ❑ No� unknown
fd
Surface water name: r—I11
Did the SSO result in a fish kill? ❑ Yes tJ NO3 dnknown
gaI` o � il
Longitude (deg rees/m In ute/second ):
Time; i_m
Incident End Dt: lTmm PM
16-12-0
(mm-dd-yyyy)
Estimated Duration (Round to nearest hour):
Volume reaching Surface waters (gallons):
If Yes, what is the estimated number of fish killed?
SPECIFIC causes) Of the SSO: ❑
❑ Severe Natural Condition ❑ Grease ❑
❑ Inflow and Infiltration [] pump Station Equipment Failur
0 Vandalism IJ Debns in line (S L/ S e c fe�L ❑
❑ Pipe Failure (Break) 1
24-hour verbal notification (name of person contacted)
C3 DWO ❑ Emergency Mgmt. pate (mm-id-yyyy): '' 2 0
Roots
Power outage
Other (Please explain in Part II)
Time (hh:mm AM/ 1k 7,0
If an SSO Is ongoing, please notify Regional Office on a daily basis until SSO onn 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 shell issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage In the county-Whz?61%-Tischarge occurred. When Is,oao 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 reference statute for further detail.
The Director, Division of Water
take enforcement action for SSOs that are required to be reported to Division
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 beer/ prevented by the exercise of reasonable control.
Part Ii must be completed to provide a justification claim for elther 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. Page 1
CS-SSO Form

10/24/2008 16:08 FAX [phone]
IR 003/022
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
Pape 2
CS-SSO Form

10/24/2008 18:08 FAX [phone]
R 004/022
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:
Page 3
cS-SSO Form

10/24/2008 18:09 FAX [phone]
R 005/022
Grease
such as cleaning, inspections, enforcement actions, past overflow
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?
❑ Yea I No ©NAQ NE
YwC No fJ NAD NE
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?
Y NoQNADNI_
Explain.
Have educational materials about grease been distributed in the past? Ye No a NA❑ NE
when?
and to whom?
Explain? L i r,,l crJ on Aq uc-' -5 17n4-e rn c-4- � oryi epaD c,
If the SSO occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation?
Were the floats clean?
i
Comments:
❑ Y.Q No C�J NAO NE
Page 4
CS-SSO Form

10/24/2008 16:09 FAX [phone]
Ia006I022
Roots Yet;]
Do you have an active root control program on the line / area in question?
❑ No ERNA0 NE
Describe
Have Cleaning and Inspections ever been increased at thls location because of roots? ❑ Yet;Q No �NA❑ NE
Explaln:
What corrective actions have been accomplished at the SSO location (and sun-ounding system if
assoclled with the ff0)?
what corrective actions are planned at the S 0 location to reduce root intrusfo?`i7
Hush hoc: WiA J r1 r '
'�` f 't G � � - �r-�t
Has the line been smoke tested or videoed within the past year? Ye No Nd# �I NE
If Yes, when?
Comments:
Page 5
OS-SSO Form

w�o3 OSS'SO
g e®ed
:%uawwoo '
��/tom �_��.<+� f,uaa ���a�.�r��- .�,,. �• �,< I - -I-t � - i r .�.-
Luopeool s14;;e sOSS p9181ej 1/1 cm;n;;uGAaJd o; pauueld eis suo1408 eMOMUaa Jay;o;e4M
;u!aldxe '9e,y;I
3N dN Q oN .�s� LAl;umaa pe;oadeul ueaq weealedn pus uo!leool OSS e41 ul sja;eM soopna 6ul;oeluoo seu!l 112 BASH
:u!eldxa 'saA 11
Zs,eMas Uuo;s 4;!M 9uolloauuao s9aao jo Mol;ul;o seomos ao!ew Aug ioedsns nQA op
3N o� o oN 0� a ,
:uleldxe 'semi
3N O dN.� o ®� Ls�etojd uo!;onpeu Ill jo; suo!;eolldds ugol jo 1Uej6 Aug ueaq ®ae41 GASH
tit J rt ��]U11,
qua !kJl� Ir�oP � ��V) 3 -� U2P .V 1 _
/J_LL+1U! r '70 5i)1� n(71/ :u!Gldxe se1�;f
�--1 0191d ;uewenojdwl le;!dep JnOA ul 5;o91o]d pelsl� UI eJe41 ON
3N �tJN L.� ON a�
:suol;oa 4on2;o 9n;e;s e41 pus kessaoau aye suoI;oe;e4M eleolpul pue uegm'so) 41
SN VN oN cjseA;Bed e4; u14l!M paoaplA 10 pe;Sa; 9� ows ueaq Bull 64; 98H
a ❑ .+ oll _
LPUGwwooej 11 plp Suo!}oe;e4M pue pe491dwoo Apn;s eyl som ua4M'9GA;I
3N ❑dN ❑ oN ®� Luolleool OSS 94; }e waloAs Uopoalloa e4; ul swalgoIll ouluuegep o; sa!pna9 mN Aug ueeq aJa4; sgH
�`� L�ea,t;Bt3l e41 my;lM
uollsool !lids S!411e SMOUMAo pOMW e3eulwlla jo eonpw o; ue)le; Useq 9As4 Suol;oa and;oaJJoa 3a4M
:se l;! uleldxa
LUI Sassaippe
1134;;!lujad Ave ul elnpe4os a eAcq no,t op jo (1UasuoO Aq 1epAO leloadS) OQS uv jepun na( eiy
9oN A N []VN Q U0413 19LII PUB MOLIUI
aaor�oo sov669vvoz xvi 64:91 9ooZ/valoL '

10/24/2008 16:09 FAX [phone]
IA 008/022
Pump Station Equipment Failure (Documentation of testing, records etc., ahoul ba provided upon request.)
What kind of notification/alarm systems are present?
Auto-dialer/telemetry (one -Way communication) ❑ Yea
❑ Yes
Audible
visual ❑ Yes
SCADA (two-way communication) ❑ Yes
Emergency Contact Signage ❑ Yes
❑ Yes
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, eta.)?
Yer❑ NO ❑ NA❑ NE
Were notifieatlon/alarm systems operable?
If no, explain,
If a pump failed. when was the last maintenance and/or Inspection performed?
Whet specifically was chsekeWmaintained?
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?
❑Ye,O No❑NA❑NE
❑ YeED No ❑ NA❑ NE
❑Ye0 No❑NA❑NI'_
❑ Ye,0 No ❑ NA ❑ N E
Page 7
CS-SSO Form

10/24/2008 16:10 FAX [phone]
Ia 008/022
If a Float problem, when were the Floats last tested? How?
If an auto-dlaler or SCADA, when was the system lest tested? How?
comments:
Page 8
CS-SSO Form

10/24/2008 16:10 FAX [phone]
[A 010/022
Power outage Documentation of testing, records, etc., should be rovided ofIternative power source
upon re ues ,
What le your alternate power or pumping source?
Lj Ygio No ❑ NA[) NE
Did It functlon 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:
CS-SSO Form Page 9

10/24/2008 16:10 FAX [phone]
la011/022
Vandalism
Provide police report number:
Was the site secured?
If Yes, how?
❑ YeC No 0 NA[D NE
Have there been previous problems with vandalism at the SSC location? ❑ YeC] No U NAQ NE
If Yes, explain:
What security rnessures have been put In place to prevent similar occurrences in the future? Y. No LZ NA❑ NE
Comments;
CS-SSO Form Page 10

10/24/2000 16:10 FAX [phone] IA 012/022
Debris in line (Rocks, sticks, rage and other Items not allowed in the collection system, ato.)
What type of debris has been found In the line?
Suspected cause or source of debris.
Are manholes In the area secure and Intact? LBIeCj No ❑ NA❑ NE
When was the area last checked/cleaned?
0 Z 110
Have cleaning and inspections ever been increased at this location due to previous problems with debris? ❑ YcZ No I_ -I NAL1 NE
Explain:
Are appropriate educational materials being developed and distributed to prevent future similar YejO No 2VA❑ NE
occurrences?
Comments:
Page 11
CS-8$0 Form

10/24/2008 16:10 FAX [phone] IaO 13/022
Other Pictures and police report, as a linable, must be available u on re uest.
De$cribe!
Were adequate equipment and resources available to fix the problem? ❑ y,,C No E�<A[I NE
If yes, explain:
if the problem could not be Immediately repaired, what actions were taken to lessen the Impact of the
SSO7
Comments:
Page 12
Cs-SSO Form

10/24/2008 16:11 FAX [phone]
[a 014/022
Pipe Failure (Break)
Pipe size (Inches)
What is the pipe material?
What Is the approximate age of linelpipe? (years old)
Is this a gravity line?
Is this a force main line?
Is the line a "High Priority" line?
Lest inspection date and findings
If a force main then,
Was the break on the force main verltical?
Was the break on the force main horizontal?
Was the leak at the Joint due to gRrket failure?
was the leak at the Joint due to split bell?
When was the last inspection or test of the nearest alr-release valve to determine of operable?
When Was the last maintenace of the air release performed?
if gravity Sewer then,
Does the line receive flow from a force main Immediately upstream of the falled section of pipe?
PVG
Zo ' ect(5
CKOO No ❑ NA [I NE
❑ YeQ<o ❑ NA❑ NE
❑ Yeo No WiWA❑ NE
❑ YE No DlA❑ NE
❑YeC] NoC�KA❑NE
❑ YaQ No E NA❑ NE
❑YwO No13rvA❑NE
�1 A
NA_
❑ Yea No ❑ NA❑ NE
If yes, what measures are taken to control the hydrogen sulfide production?
When was the line last inspected or videoed? rri5'pe44Cd 2 r
Page 13
CS-SSO Form

10/24/2008 16:11 FAX [phone] IM015/022
if line collapsed, what is the condition of the line up and down stream of the failure?
NA
What type of repair was made?
Is the repair temporary or permanent?
If temporary, when is the permanent repair planned? ^�.' NA ❑ Yes❑ No LJNA❑ NE
Have there been other failures of this line In the pest five years?
If so, then describe
Page 14
CS-SSO Form

10/24/2009 16:11 FAX [phone]
System Visitation
ORC
Backup
Name:
cart#
Date visited:
Time visited:
How was the SSO remedlated (i.e. Stopped and cleaned Up)7
- -1roMCP
See. Cl 1-ac 'I . cd Ilp
As a representative for the }ag onsible party, I certify that the information
Person submitting claim: P )Pr'W d•Z
[A 016/022
DaVIC, b
'W W 37
1. rjba1 Q � --
iS:�S
in this re ort is true and accurate to
Date: 1 Ol) LJiC S
1 % , Title: liance MCI
Signature: lfLrj
Telephone Number:
Any additional Information desired to be submitted should be sent to the appropriate I]Ivlslon Regional OfflOe within five days of tint
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 15
CS-S50 Form

. 10/24/2000 16:11 FAX [phone]
[a 017/022
C.-o I oil SIS426m Saw ti+-r7 a f, ovCr7 I C,j lzj2-fb c14
l
P A
70� r � C.G-+..+r �•e� -
�
��) a4,.,ex z 1�7 1641 6P

10/24/2000 16:12 FAX [phone]
[a 018/022
/6)01(O,d CW L)CL, ,
CAR S s C_
5wb- �a�5;n b�b8� z
Y1i G
r
1(r37
7 ck Cre @ y
)pD 3, C 7 / 6", G /

10/24/2008 18:12 FAX. [phone]
IA 019/022

10/24/2008 16:12 FAX [phone] Ia020/022
OCT-23-2006 THU 02:18 PM WATER TECH LABS, ]NC. FAX NU. d-ed;latibinl r,
UL
li '1 ', , .

10/24/2006 16:12 FAX [phone]
ZT-23-2008 THU 02118 PM WAFER TECH LABS, INC. FAX Nu, bej;jutiblul
upir cROccif milw .Inc.
POST OFFIC$ BOX 1050 • #5 PINEWOOD PLAZA DR.
�I3AIviTE FALLS, NORT14 WOUNA 28 W
SAMPLE; Country Valley CQLLSCYIoN DATE: 10120/2008
PERMITA, NCO058743 COLLFCT►ON TIME.' 15N
ADDRESS., Aqua North Crarollne RgCEIVED PATE., 10/20/2008
P.Q, Box 550 RECpIIiED TIME; 2000
Denver, NO 28037 REPORTED; 10/23/2008
r
DATE,
.1i J,
ANALYST
ANALYSIS N17S v ,', .. , ,1I LABS,. 1 iI
11DpmL 1GlZDlI)8 lra
y�
n;J
® p
ANALYSIS OF , UNITS DAT iii ANALYST
Feoe! ColHOFln '2,700 I100mL 10/20106 Sig
ANALYSIS DOWN UNITS
FOC 31 0011foari 3-22,300 110DmL
DA%F
10120r�9
ANALYSr
Ira
Lod 1D: OA10-445 REPORTED BY• NC: I trams LAME7 rr
Tony Grag$, Lab Supervisor
[a 021/022
r I UL
s

J '
10/24/2008 16:13 FAX [phone]
OCT-23-2008 THU 02 ,18 PH WATER TECH LABS, INC, h h Nu, bees-JUoo r o L
6017=47=lf L011501m,
POST OFFICE BOX 1054 t 415 P1NMOOD PLAZA 0A.
43RAN)TE FALLS, NORTH CAROLINA 96.M
(M) 306-44 44
SAMP[.E. Country valley Cot-LECMN DATE., 10/21/2008
PERMIT& N00058743 CO[4ECT!ON Mg., 1432
ADDRESS: Aqua North Caroline f2Hcmv5D DATE: 10/21/2008
.P.O. sox 869 RECEWED TIME; 1607
Denver, NO 28037
REPORTED; 10/23/2008
ANALYSIS EFF UNITS oATF ANALYST
BITE Ff °b°r'? r1 %A+:�'1_ . -Q Lam.I
rt0ow".
ANALYSIS UP UNITS., DATA ANALYST
Fecal Conform 3,200 /100mL 101�1IJ� lv�
ANALYSIS DOWN. � �' . •-' ' pAT'. , , ANALYST
Fowl C411form P61e00 /100ml. 10121IDo lrg
LOG ID; 0810-496 UPORTED BY, NC CERMFLED LAki 4 W
ff� �
t Teeny C3ma, Lab Supervisor
[it 022/022
r, u13

. a
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
June 3, 2009
CERTIFIED MMAIL
RETURN RECEIPT REQUESTED
7007 1490 0004 4505 7384
Mr. Donald R. Innes
6255 Hwy 150 E
Denver, NC 28037
Subject: Deemed Permitted Wastewater Collection Systems
Permittee: Donald Innes
Facility: Boch's MHP Wastewater Collection System
Catawba County
Dear Mr. Innes:
1. In accordance with North Carolina Administrative Code 15A NCAC 02T .0400, et seq., wastewater
collection systems having an actual, permitted or Division approved average daily flow of less than
200,000 gallons per day are deemed permitted. As such, the collection system serving your facility is
deemed permitted and you are authorized to operate and maintain the system.
2. You are highly encouraged to review 15A NCAC 02T .0400, et seq., in detail. These rules contain several
requirements with which you must comply as the owner of a deemed permitted collection system, or
permittee. These requirements are summarized below:
a. 15A NCAC 02T .0403(a)(1) requires that the sewer system be effectively maintained and operated at
all times to prevent discharge to land or surface waters and any contravention of ground or surface
water standards.
b. 15A NCAC 02T .0403(a)(2) requires that a map of the wastewater collection system be developed
and actively maintained.
c. 15A NCAC 02T .0403(a)(3) requires that an operation and maintenance plan be developed and
implemented, which includes pump station inspection frequency, preventative maintenance schedule,
spare parts inventory and overflow response.
Mooresville Regional Office
Location: 610 East Center Ave., Suite 301 Mooresville, NC 28115
Phone: [phone] Fax: [phone] Customer Service: 1-877-623-6748
Internet: mm.ncNaterquality.org
An Equal Opportunity ',Affirmative Action Employer — 50% Recycled/10% Post Consumer paper
No thCarohna
atimally

_,
Innes
Boch"s MHP
June 2009
Page 2 of 3
d.- 15A NCAC 02T .0403(a)(4) requires that the permittee or its representative inspect
pump stations not connected to a telemetry system (i.e., remote alarm system) every
day (Le., 365 days per year) and pump stations connected to a telemetry system at
least once per week.
e. 15A NCAC 02T .0403(a)(5) requires that the permittee or its representative inspect
high -priority sewers, as defined in 15A NCAC 02T .0402(2), at least once every six -
months and document the inspections.
f. 15A NCAC 02T .0403(a)(6) requires that the permittee or its representative conduct a
general observation of the entire sewer system at least once per year.
g. 15A NCAC 02T .0403(a)(7) requires that overflows and bypasses from the system be
reported to the Division's Mooresville regional office in accordance with 15A NCAC
02B .0506(a), and that public notice must be provided as required by G.S. 143-
215.1 C. During office hours of Monday thru Friday verbal notification may be made by
calling the Mooresville Regional Office at 704-663-1699, for after ours weekends and
holidays you should contact 1-800-858-0368.
h. 15A NCAC 02T .0403(a)(8)(A-C) requires that a grease control program be developed
and implemented as follows:
1. For publicly owned collection systems the grease control program shall include at
least bi-annual distribution of grease education materials for both commercial
and residential users and the legal means to require grease interceptors for new
construction and, if necessary, retrofit of grease interceptors at existing
establishments. The plan shall also include legal means for inspections of the
grease interceptors, enforcement for violators and to control grease entering the
system from other public and private satellite sewer systems.
2. Grease education materials shall be distributed more often than required above if
necessary to prevent grease -related sanitary sewer overflows.
15A NCAC 02T .0403(a)(9) requires that right-of-ways and easements be maintained
in the full easement width for personnel and equipment accessibility.
j. 15A NCAC 02T .0403(a)(10) requires that documentation 'be kept for all activities you
undertake to comply with the requirements of 15A NCAC 02T .0403, subparagraphs
(a)(1) through (a)(9), for a minimum of three years, with the exception of the` map,
which shall be maintained for the life of the system.
3. Please be aware that the Division may conduct inspections of your collection system to
determine your compliance with these rules. You should therefore be fully prepared, at

.11
lnnes'
"Boch"s MHP
June 2009
Page 3 of 3
all times, to demonstrate compliance. These inspections include both a field review of the
physical system, as well as a detailed review of all required documentation.
4. An official copy of the 15A NCAC 02T .0400 rules, can be accessed via the website of the
NC Office of Administrative Hearings, at http://www.oah.state.nc.us/rules/. You can either
download and print a copy of the rules, or simply view them online.
5. The Division understands that the implications of these rules may be difficult to fully
understand. Furthermore, Division inspectors expect to see specific conditions and items
during inspections to assess compliance with the rules. We therefore highly encourage
you to call upon our inspectors in the Mooresville Regional Office regarding any questions
you may have about the rules and their meaning.
C^
Finally, you
must understand that, in accordance with NC
General Statute 143-215.6A,
the Division
may assess civil penalties not
to _exrPPrl -9- nnn per violation, for
_
,ion to this matter.
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Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#
Incident Number from BIMS 20130QE5'bI
Incident Reviewed (Date):
Incident Action Taken: BPJ
Spill Date�� yt�
Reported Date�"a��
Reported To SWP Staff or EM Staff
NOV-2013-DV
DV-2013-
Time m/ m
Time am/ m
�- k . Ad t c3C z- ,
Reported By ���' ��-Q�-' Phone
Address of Spill iZ%'1
County
City
p lam' ��-�- - � V)'& '` U uke, L.
Cause of Spill r ' L.
Total Estimated Gallons Est. Gal to Stream
lU I -F, I -k n rLA .-k-O ��
Stream R IOZ Fish Kill: Yes No umber Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

Permit #
Owner and Facility Name
WOCS00253
Bradfield Farms Water Company CS
WQCS00196
Carolina Water Service Cabarrus Woods CS
WQCS00233
Carolina Water -Service Hemby Acres CS
WQCS00001
Charlotte -Mecklenburg CS
WQCS00016
City of Albemarle CS
WQCS00046
City of Belmont CS
WQCS00107
City of Bessemer City CS
WQCS00089
City of Cherryville CS-
WQCS00221
City of Claremont CS
WQCS00326
City of Concord CS
WQCS00088
City of Conover CS
WQCS00017
City of Gastonia CS
WQCS00020
City of Hickory CS
WQCS00327
City of Kannapolis CS
WQCS00036
City of Kings Mountain CS
WQCS00040
City of Lincolnton CS
WQCS00164
City of Lowell CS
WQCS00026 '
City of Monroe CS
WQCS00059
City of Mount Holly CS
WQCS00044
City of Newton CS
WQCS00019
City of Salisbury CS
WQCS00037
City of Shelby CS
WOCS00030 -
City of Statesville CS
WQCS00149
East Lincoln CS
Deemed Permitted
Permit#
Owner and Facility Name
WQCSDO130
Brooks Food Group -Brooks Food Group
WQCSDO114
Charlotte Mecklenburg Schools - Misc Laterals
WQCSDO057
City of High Shoals CS
WQCSDO117
Duke Energy Marshall Steam Station
WQCSD0257
Fallston
WQCSDO116
Gopse Creek Utilities Fairfield Plantation WWTP
WQCSDO101
Harborside Dev LLC-Midtown T CS
WQCSDO095
Kennerly Dev. ,Group LLC-Boardwalk Villas CS
WQCSDO098
Kennerly Dev, Group LLC-Kings Point CS
WQCSDO105
Kennerly Dev. Group LLC-Moon Bay Condos CS
WQCSDO107
Kennerly Dev. Group LLC-Schooner Bay CS
WQCSDO099
Kennerly Dev. Group LLC-Spinnaker Point CS
WQCSD0258
Kingstown
WQCSDO112
Lake Norman -South Point CS
WQCSDO104
Lake Norman -Villas S Harbour CS
WQCSDO102
Lake Norman -Vineyard Pt Resort CS
Permit #
Owner and Facility Name
'WQCS00171
Greater Badin CS
WQCSD0322
Aqua Country Woods East CS
WQCS00222
Town of Boiling Springs CS
WQCS00341
Town of China Grove CS
WQCS00231
Town.of Cleveland CS
WQCS00058
Town of Cramerton CS
WQCS00165
Town of Dallas CS
WQCS00342
Town of E. Spencer CS,
WQCS00328
Town of Harrisburg CS
WQCS00343
Town of Landis CS
WQCS00310
Town of Longview CS
WQCS00120
Town of Maiden CS
WQCS00344
Town of Marshville CS
WQCS00043
Town of Mooresville CS
WQCSDO125
Town of Mt Pleasant CS.
WQCS00153
Town of Norwood CS
WQCS00190
Town of Oakboro CS
WQCS00325
Town of Stanfield CS
WQC800180
Town of Stanley CS
WQCS00135
Town of Taylorsville CS
WQCS00258
Town of Troutman CS
WQCSOD345
Town of Wingate CS
WQCS00054
Union County CS
WQCS00009
WSA Cabarrus Co. CS
Permit #
Owner and Facility Name
WQCSDO064
Lincoln County CS
WQCSDO097
Martin Dev Gp-N Point & Portside CS
WQCSDD120
Martin Marietta Mallard Creek
WQCSDDO19
Town of Richfield CS
WQCSDO024
Town of Grover CS
WQCSDO038
Town of McAdenville CS
WQCSD0002
Town of Ranlo CS
WQCSDO049
Town of Spencer Mountain CS
WOCSDO252 All spills which do not have a permit
number assigned

May 10 13 12:55io 828-322-1405 10. 1
�.r
.aA10
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y C
Fors„ cs—sso
Collection System Sanitary Sewer Overflow Reporting Form
PART I
Tf 7S ftiriit Sf G%� bL' ici?Pfiit E �, v u c o^f.prvprioic Dui1 t iicyivi iai v1�i1G 'VViii1111 AIV0 VUyn v u c uSt Mituvvic�uu v
the sanitary sewer overflow (SSO).
Permit Number: k �' d I 1 1% CS# if active, otherwise use treatment plant NC/WQ#) O l ��
Facility: 1�I !t. 0 Incident # oZ
Owner ���� i P�a`� Region:
City: County:��
Source of SSO (check applicable) : ❑ Sanitary Sewer Pump Station
SPECIFIC location of the SSO (be consistent iq description from past reports or documentation - i.e. Pump Station 6,
Manhole at Westall & Bragg Street, etc.) : �� i�:�ml2 ����
Latitude (deg rees/minutelsecond): Lon gitude(degrees/minutelsecond)-
incident Started Dt: Time: t Incident End Dt: CS ` Time• ^ -moo
(mm-dd-yyyy) hh:mm AMIPM (mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: l 0�Z7 gallons Estimated Duration (Round to nearest hour):
Describe how the volume was determined: I�4 EIS'
Weather conditions during SSO event
Did SSO reach surface waters? Yes ❑ Ni, Unknown Volume reaching surface waters (gallons):
Surface water name:
Did the SSO result in a fish kill? ❑ Yes M 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 ❑ Debris in line ❑ Other (Please explain)
Immediate 24-hour verbal notification reported to: sue- A%-) L6�:;
DWQ ❑ Emergency Mgmt. Date (mm-dd-yyyy): 1 114Time (hh:mm AWPM). +0 Z-�`ti j>rrl
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 24-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 _t_o_b_e_ reported_ to Division unless it
is demonstrated that
1) the discharge was caused by severe natural conditions and there were no feasible altematives 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 Il IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 7, 2003 Page 1

May 10 13 12:55p
828-322-1405 p.2
r �
be
provided of altemative power source upc
What is your alternate power or pumping source?
Did it function property?
Describe?
\t�1A '�, � � i v-�-.J� � s�d-� c iLv✓� �:.,...,,� �,,,,. 0 tcl��2 ��. '�c..� �. r.� � ��
When was the alternate power or pumping source last tested under load? `3 �k2
i4 JA
If caused by a weather event, how much advance warning did you have and what actions were taken to
prepare for the event?
Comments: ,.
Q- b(Lirr.� i ri - Y-e i IF LO---x t +
Vandalism
Provide police report number
Was the site secured?
If Yes, how?
NA LINE
❑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 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 fine?
How could it have gotten there?
Are manholes in the area secure and intact? ❑Yes❑ No❑NA❑NE
CS-5SO Form October 7, 2003 Page 6

Mai 10 13 12:55p 828-322-1405 p.2
Power outage (Documentation of testing, records, etc., should be
provided of alternative power source upon request.)
What is your alternate power or pumping source?
n
Did it function property? ❑Yes❑ NO❑NA❑NE
Describe?
1ti1R �1�C�-1 �-�^�� 1R lC �V✓t �r� �i.J_vy�� �2� Tr^aG Sir— L- 'r.-s,'1 I
When was the alternate power or pumping source last tested under load? '-3>kk2 V-03- h i"t-"j,
i-4 1'�
If caused by a weather event, how much advance warning did you have and what actions were taken to
prepare for the event?
Comments:
YN. i�r" 1-11 `0, i" _ F Lo�'Ly t y-1
Vandalism
Provide police report number:
Was the site secured? ❑ Y es❑ No ❑ NA ❑ NE
If Yes, how?
Have there been previobs problems with vandalism at the SSO location? El Yes[] No ❑NA ❑NE
If Yes, explain:
What security measures have been put in place to prevent similar occurrences in the future? ❑Yes❑ Nor 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 7, 2003 Page 6

Mai 10 13 12:56p
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: -
5Y�""✓1 V►Vq-e
Signature:.
4--RJ
828-322-1405
Date: ' f 1 `5 � (J
Title:
Telephone Number: �23�3 - 7419:-7 ""(I
Any additionai 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).
p.3
CS-SSO Form October 7, 2003
Page 8