WQCS00258_Regional Office Historical File Pre 2018 (2)

CERTIFIED MAIL: 7015 1520 0002 8376 2098
RETURN RECEIPT REQUESTED
August 22, 2019
Elbert H Richardson
Town of Troutman
PO BOX 26
Troutman, NC 28166-0026
SUBJECT: NOTICE OF VIOLATION & INTENT TO ISSUE CIVIL PENALTY
Tracking No.: NOV-2019-DV-0335
aitar Sewepi9verflow&-Juma--2019
Collection System Permit No., WQCS00258
Troutman Collection System
Iredell County
Dear Mr. Richardson:
A review has been conducted of the self -reported Sanitary Sewer Overflows (SSO's) 5-Day Report/s submitted by
Town of Troutman. The Division's Mooresville Regional Office concludes that the Town of Troutman violated
Permit Condition I (2) of Permit No. WQCS00258 by failing to effectively manage, maintain, and operate their
collection_system_so_that_ther_e_is_no_SSO_(Sanitary Sewer Overflow) to the_land_or_surface_waters_and-the-SSO __
constituted making an outlet to waters of the State for purposes of G.S. 143-215.1(a)(1), for which .a permit is
required by G.S. 143-215.1.
The Mooresville Regional Office is providing the Town of Troutman an opportunity to provide evidence and
justification as to why the Town of Troutman should not be assessed a civil penalty for the violation(s) that are
summarized below:
Incident Start Duration
Number Date (Mips) Location
Total Vol
Total Surface
Vol Water
Cause (Gals) (Gals) DWR Action
201901021 6/8/2019 289 Westmoreland Debris in line 75 75 Notice of Violation
Road No 5-day report

K-
This Notice of Violation / Notice of Intent to Enforce (NOV/NOI) is being issued for the noted violation. Pursuant
to G.S. 143-215.6A, a civil penalty of not more than twenty-five thousand dollars ($25,000.00) may be assessed
against any person who violates or fails to act in accordance with the terms, conditions, or requirements of any
permit issued pursuant to G.S. 143-215.1.
This office requests that you respond to this Notice, in writing, within 10 business days of its
receipt. In your response, you should address the causes of non-compliance, remedial actions, and all other
actions taken to prevent the recurrence of similar situations. The response to this correspondence will be
considered in this process. Enforcement decisions will also. be based on volume spilled, volume reaching surface
waters, duration and gravity, impacts to public health, fish kills or recreational area closures: Other factors
considered in, determining the amount of the civil penalty are the violator's history of non-compliance, the cost of
rectifying the damage, whether the spill was intentional and whether money was saved by non-compliance.
I :2 itact Michael Meilinger with the Water Quality Section in
ti a amail at [e-mail].
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igned by:
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asinger, Regional Supervisor
ity-Regi©nai-®perations-See iu
Regional Office
Water Resources, NCDEQ

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Director
NORTH CAROLINA
Environmental Quality
CERTIFIED MAIL #: 7018-0360-0002-2099-2151
RETURN RECEIPT REQUESTED
May 28, 2019
Elbert H Richardson
Town of Troutman
PO BOX 26
Troutman, NC 28166-0026
SUBJECT: NOTICE OF VIOLATION
Tracking Number: NOV-2019-DV-0236
Sanitary Sewer Overflows - April 2019
Collection System Permit No. WQCS00258
Troutman Collection System
Iredell County
Dear Mr. Richardson:
The self -reported Sanitary Sewer Overflow (SSO) 5-Day Report submitted by Town of Troutman indicates
violations of permit conditions stipulated in the subject permit and North Carolina G.S. 143-21.5.1. Violations include
failing to effectively manage, maintain, and operate the subject collection system so that there is no SSO to the
land or surface waters and making an outlet to waters of the State for purposes of G.S. 143-215._i(a)(1), for
which a permit is required.
Specific incident(s) cited in the subject report.include the following:
Total Vol
Total Surface
Incident Start Duration Vol Water
Number Date (Mins) Location Cause (Gals) (Gals) DWR Action
201900726 4/14/2019 30 237 West Thomas St Debris in line, Grease 800 350 Notice of Violation
Remedial actions, if not already implemented, should be taken to correct the above noncompliance. Please submit
a written response to this Notice of Violation. Your response is to be received by the regional office within 15
business days following receipt of this violation. Please include any additional documentation about this incident(s)
in the response. The submittal will be considered in determining whether the Division will assess a civil penalty for
the cited violations.
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May 17, 2016
Elbert H Richardson
Town of Troutman
PO BOX 26
Troutman, NC 28166-0026
SUBJECT: Sanitary Sewer Overflows - April 2016
Collection System Permit No. WQCS00258.
Troutman Collection System
Iredell County
Dear Mr. Richardson:
A review has been conducted of the self -reported Sanitary Sewer Overflow (SSO) 5-Day Report submitted by
Town of Troutman. This review has shown the Town of Troutman to be in violation of the requirements found in
the subject permit and/or North Carolina G.S. 143-215.1(a)(1). The violations that occurred are summarized
below:
Total Vol
Total Surface
Incident Start Duration Vol Water
Number Date (Mina) Location Cause (Gals) (Gals) DWR Action
201600855 4/16/2016 45 Cedar Lane pump stn. Roots 300 75 No Action
Remedial actions, if not already implemented, should be taken to correct the above noncompliance. Please note
that the Division of Water Resources (DWR) began assessing civil penalties for severe and/or repeat SSOs
starting December 1, 2007. Enforcement decisions are based on volume spilled, volume reaching surface waters,
duration, gravity, impacts to public- health, fish kills and other factors.
State of North Carolina I Environmental Quality I Water Resources
610 East Center Avenue, Suite 301, Mooresville, NC 28115
764_661_16g9

If you should have any questions, please do not hesitate to contact Lon Snider with the Water Quality Section in
the Mooresville Regional Office at 704-663-1699 or via email at [e-mail]:
Sincerely,
,I-
W. Corey Basinger, Regional Supervisor
Water Quality Regional Operations Section
Mooresville Regional Office
Division of Water Resources, NCDEQ
Cc: Mooresville Regional Office - WQS File
Central Files, Water Quality Section
State of North Carolina i Environmental Quality I Water Resources
610 East Center Avenue, Suite 301, Mooresville, NC 28115
704-663-1699

-P-11
Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#
Incident Number from BIMS 20160 0 7�5 6
Incident Reviewed (Date):
Incident Action Taken: BPJ
NOV-2016-DV
DV-2016-
Spill Date -1 d Time ��r am/ m m ft 5���,
Reported Date 3Time eV pm
Reported To RO WQ Staff or EM Staff ge,41 e_
Reported B r o�v� b. on� Phone `tOl-F 02---
Address of Spill
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County .� )e/,/ City ro v-Zmn ern
Cause of Spill NuA 0"
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Total Estimated Gallons Est. Gal to Stream L .-0
Stream® Wl-er� &eeh 6 am Classification
Fish Kill: Yes Number" Species
Non Required Initial Information and other comments relating to SSO incident:
Response time 2-5minutes Zone Manhole #
Duration of SSO �S—MN5 ,

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sanitary sewer ('SSO)4
P fmit Number. WQ0,966 8, ('W" _Q'So -"if,active ;,bthoiWisouse wQbSb#)
Fadility:TROUTMAN '160ehtA:`2; Owner TOWN'bF-T,.RouTMA'N:
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Weather C(Jnditi I ont'd . uringthe SSO event, DP.V'
bid'tIfeS­S'ZYes, F-1 ,No: M o6knowrT
V61umb,neachiOg surface 'waters .: LGQ,gall.ons' Sarfate'water name;; WEATHER8 -CREEK
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If Y'es., Wli.at.As,the.estimai6d. nqmber:d-flsfi- killed''?-
80MIPIC-causes) of the S,S'O.l
n,.8evere Natural Conditi6ris! ;Grease: nkoo't's.
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Per G S. 143-216AC(0); th0'.oWqqr,.,pr opqr,jtqr
of any f-system:shall: wastewater co ll� ettiqr
in'the drge. b 1,0 the 6V6rit`6f:a- 00,'galldn§ bt ffibnJ of untreated wdstdWatiatfortt e surface -Waters ;of the, - State;
issue:
,press releasetoall print and electronic, news mediathat� provide �general coverage in 'the, county where: the
iSC , �krgq_ The 1. 'th­,,;?4-'h6bn§afI&
o� _bfthb-Id' h' T4 b bed,
the -ow owner oroperator-has-d4ermined -that 11 Ihe,d - ischargebas reached surfacewatem of -the gtai6;
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lhthe'.7event ofa,di of . 15,000 �goj6n more of untreated' wastewater A the surface waters of the �tiaie'i
h
the, in-,..a-lnewspaper b _rgq,,
publis'h­,a.­n6fice o discharge aving genpral.,cir ulatjoqjn.lh�,�qpGht�, in, which clj.sC-jq
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rge:,thbti�rigni-canify��#�.-ci6d�bythodisdhargOThe
Regional 'Office 'shall determine whichcounties'are sigrilicanily. affected 6y the.dischargp arid,`shalf-approve theJorm-
and qohterif of the., nib-,tide.'an'd Ahb" notice published:
) ' _ ­ . 0'h4t!I '. is pu � th'd's_g .
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When.was the last time this specifc line (or'tivetwell), was cleaned
Never line was put -jkjo 2015
Do. you havean en't6rcea6fe greas& ordinanGe that. requires,new or retrofit�of
Orb piE�Orapslnterceptors..
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El NA
❑ NE
Have Ahere•been recent;inspediortand/or�enforc6ment"actiong'tak6rtioiI near--,
by. restaurants:orrolhernonresidbnffai-.qrease codfribuiors.5
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When?
If yes;,tdes(;Nb0 thew
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Explain:
1 lave educational -t-- -bp -b- -Wbutedlp� h�. p
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and, fo whom.
lf,,fhe!5801,occurred:at,a.pump:station, ,I,vihen wasbeweivell and pumps "las . t checked,
f6t`g'r'eape E'!c'p-'umqIaffqrh,:
Were -the floats- clean? Yes
No
QNA- . Q.,NE
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0 ' ther - (Pidures.and Pofice report, as"apolic6b(g, must be.,avallgible. upon, reguegLt.)
Describe-
,Were'adequafe equlprneni°and resources-avaii6le4oi fix :fhe pro- bl'eni7 ;Z ""ees El No :EIINA El: NE
if, Y6b, Ox' -j� 0 p ih.: je t 'fb' 'd -' a t, _machine --thorbUqhjyFb. ., O#t a_ e ine.
�ifihe pr9biern couid"hoitre immediately repairedwh'at'a"dtions
_EjN6 ZNA El NE
wereAakenlo.lesisen'lhe imipact ofthe S80,?
Oommenfs: tine has been added to :higbpribi4y. list and win:,be.,cleanedbi annuAll
Tage,11

System Visitation
ORC ® Yes
Backup ❑ Yes
Name: ADAM LIPPARD
Certification Number. 996195
Date visited: 03/22/2016
Time visited: 7:05 AM
How was the SSO remediated (i./e. Stopped and cleaned up)?
Line was unstopped with high pressure jetting machine. Lime was spread to neutralize odor
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: Adam Lippard Date: 3/22/2016
Signature: -�' - Title:'
Telephone Number: 704-902-1451
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five
business 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).
Form CS-SSO
Page 13

Collection System SSO 24-Hour Notification
5 -P
Collection System: Number and Name WQCS#
Incident Number from BIMS 20160
Incident Reviewed (Date): 2-® %— 6
Incident Action Taken: BPJ
NOV-2016-DV
DV-2016-
Spill Date Z-' % (- /� Time r /S amfp'M
Reported Date,` Time Q;a i m
Reported To RO WQJ Staff or ,ECM Staff
Reported By T �✓ / �q Phone
f P
Address of Spill
County L,T1 City n W-rkt eE- 1
Cause of Spill
Total Estimated Gallons 7SO = " Est Gai o
? fir; �dq-rx t(",A S �1�� �r' + C n
Stream �reanfiCtassi if catior
Fish Kill: Yes N9 Number Species -
2--
Non Required Initial Information and other comments relating to SSO i
-10
dent: IV
Response time minutes Zone Manhole #
Duration of SSO 0 t'�-O 10,4—
V s-v c 4 ., wit a o.-
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WQC:500054 Uniol CeurdyCS
v 0.5 0149 East Li uoln CS
Val C:aLmrmn Cc. CS .
Deemed Permitttsff
p: mifE Owner an;d Fag[lity jal2ma
ermyl~ nr_r-ajtd Facilid` NArne
WQCSZM130 BrocAs, Fard Grrrup.Oroa:� Pcod.Gnaup
WOCSD0 I-2A Lincalr' Cov in q CS
'a"`'>"IOS3 a0114 Char.lotUe Meckten rq'-,.Moak.- Misc La'arals
IOC-S.D00]F Mirlin Dav Gp-N ,aoinl: &.12orWde CS
4 OOS M7 C'-yeJ vi3h $h sls
'P'JQCSD0120 Marlin idsfialta Mallard crcck -
tiP1CX-D0 17 Duke E en
Ir` GC8E S Yawn •af Riddield OS
WOO&M257 ,Faflsbarl
' D[302 Tc�r�af ray r wi -.
"V0QC3D01j,S I' ek,'Jiililies F:airrMid B1a n Inn i+NI
WQGSDOD38 Town of l cAdsaville C
'P��Ld.0 th.!1 �D1 Fiat * Sitl aE' LL�-'! 1•F��o', r7 T '' -
tidCl .D4Li0• `f r'n r}d r aa�l CS .
44' =.14036 Xeme:rfy Desf_.Group LLCtEroWy�-dli€Win C5.W.Q
ioa4rli V,.Spenr^er Mauniairl CS
W$10O598 KerinerlY'Dev.'GroL5bl,!'.,C',i`taf'c4n['C8
IND08M)1 15 _Kennerly. --v. Ofoup a LC -Mom Bay Condos CSVo
.C,3252 jell:sp lv 'Mill° h do 175t tra�`a it pnl"rllt
' •'b'�'�QO'1�7� f���r.�r9x' Dieu: C•�-pup LL��ch+�or.,vf �a� � . .
.: mC nbe; assipned
Vk'=813MEN K.6nnedy Dee, Group LL pim-eker Pbinl CS
. '�'�'•fl.CS;Cr+3�5� �li�ul�Wri .: ... :..:- , .. .. .......
..........:_ .: _
WO0 Pa112 URe Normk South Poial (,',q
WQTCSDCIIC Lake gxnan,Villas S-Harbour CS
-
�ATI.0 K-0i02 1-.:ke Nc-,rr,,=-n-Vineyarr PI Rs: ft C$

Siate.-of North,Caroliva
Department ofEnvironmedial Unality,
DMA6n of Wker-Resources
Collection -System Sanitary Sewer OverflowsRepqrtwg'FQTM
elilvlslon,OMAte 'Res-ourices FOiTwcs-sso
---------------- -
pART
Thi1s1,',fc?j( 10fi fknowledge ,�,doria(6 QWP a[D -five the first.'of,thq Redi _ffipe withinf
sanitary seweoverflow P6tmit"Number.,: 'WQC002$ 81L '(W QGS#if'activq; otherwise,,useVVQCSD
Facility: Town of Troutinani. Incident#A Owner,,T6wn of Tioutman
Region .M96re, V 116 City.. TrQutmqn -Qpu6ty: kedpil
�S6urce-&f SM(checkapplfcabley -Sanitary Sewer. Ej Pump -,Station I Lift Station_
16-qatiqq of the SSO. (be consistent inAdsbtipt'(qn frb— ' t­­ rt— d­ io P M pa q . repo .. qp�, ppumentat i.e. ,,..Vmp:
Station, , 'b' �'_h17 gg Street, ,etc. Wiioajr.'� Thomas k R.' W.
p,e..q(We.%qII & _Bga
'M - 6 41 17
Latitude
tii6de(q'egroes/minUte/Seoond): Ldngk
[heidonf'Siartiod bt- 1/1 02615 tme405' Incident End Dt-.,2/'I' 6/2011J --r '5
jtnet, 4-3
PM M .-mm) AMI '-6d-y ,.(hh:mm),A IPM
�yy (hh (mm Yyy,
Estif*o _-Vokiffie of the S.SO:` 750:gdUbns Estimated Qdaluoh.,(round to nearest Kc4f)".5.; N50 . r(sY:
Describe K60,thd Wuffi6w4s d&td"ine -:visual estimatio
n
Weather 66tiditio'nsduCj-ng�,'the,SSO','eV,eht.-. Clear
Did the aSOjedch.iS_'uff;ac t6r-s? 0: YOs .No 'TT,Uhkn ,U
nknown
,V surface $qrf6q6 wafern6me: Hicks Q-Tpolk,
,,j6Iumer&achin4,s rfa
Did El Yes� 0 No 0_,Qbknow in
,fyos,what is the estimated; number dffish killed?
SPEC
IFIC 1. of t . he'.S 0:,
_).
Flseve�rO--NRoots *ral. Conditions jE dr6pso. E]Roo ninflow & Inblfrd'On
0Pi1ftiO%S!atibn Eauifiinept Failure: n Power Outage []Vbrjd9IisM; Z'.bebiis'ih 66 FlPipiq'Failure •(Break)
Other (Please Raff"16
14-hourverbal'notification, , name ofperson contacted BruceTaffis%
,ObWR _nEmorpancy Management Date(mM7dd-yyy): 02-1-7-2615TIme-, (hh:mm AM1pM'):Y!Q'O AM
Per G.&­14SrZ15.1 (b), the owner or operatur qfanywast6water colleption,systein-shalk
In the event ofa discharger.,of. I" boo, gallons',or more -of untreated wastewaierto the surface'wgtbrs:of the Sfate,,Itsue
:a
-r&�::6a-86.to 611OWiir-
fi_t and el6c,tfbfiic `M,Wsmedia .that p r. ,o,vide"g.'eneral' coverage
oyerage
n the
'cojhty­W`h6t6 the
"discharge occurred -:setting -.out 6dtai discharge. 'Thepresvreledse,Sfiall,beiSuedwiffiih24h6urs,after
the owner orp6rat rh s,deter med that the dikfsroefils�.reaPhed'spffacIe:waterof the State:.
.In :qb!Je ev'nt f ,4schar''-aillons ormore-, of'untrbat'ed'wastewater tothe surface waters 6tefs of the State
p4h�eroay00oapef,h ving general circUlatibr:n the county in whichhe discharge' qeg5g
occursand in each countownstreanfrom the of discharge4haf.issignifcanflyafiec ed by the discharge The
count Aff approve. the forth Regional Office shalVd6telmlinephich es are sq _,y the di4chiargb.1nds a
and, content of the notice and.the n'e'Ws'Pap'er's,:in,Whii;h-,the '
WHETHER ':OF"NOT PART Il MWMPLETEU, PAGE'13
ForhiCS"SS

.Grease -Mocument4tion subh-,as cleading, Nspediom enforcement actions
pastoverfbw. reports. educational"
m6terialland distributbn date, etc: should be available upon, requ6stj
When --was ihe last6tne--'fhis,spe&ific.iine,;(6r wet w6fi), was�clearie-dl
bovcio have an enforceable grease ordinance AIhat,requirieI-I new or- retrofit- of
1 1
,,grease,- traps/interceptQrs? 7'PS,
ElNo? ❑NA M NE'
�
Have there,b en,r.e.cO, in-sp0qt,iph andW. nf fbeirdr"t,,Odtibn§.'taken on'near-
on
lj
svr�taut4Rrestaurants n6hr�t dprialgrq�pp-qoq nutpp,
Z6ENA tNE
X am.'.:
,Have iffibrei." been ,'oth'. qpOgbt, blockages in this :areastli W re:61so caused
Yes; by,.grease Ell
Nij TIO 'ETNO
If yes; .!db8Oribe?,tftem.-
Have�cleanir�g and i6spec6ons-.-everbeen done afthis"locafi601'Yes
El No QNA-❑ WE
FkO 46ih-t
H'ave,,ed-ucafibnal,m;jt6r.jai'�abouf -Rreasezbeen distribuied'in the past.?- fljY es
6
0 NaEINA El kE
When':
and :to wl M'.;
Explain:,
the SSb-qqcurrpd::dig�pqrnp:station, - w6qqwas the vot-w last checked;
..e @�d p4WD.sj
,for gr'��se:'a'm, u'mu atlon:.
-
r0'1( "floPts 0* El No E
Comments: F,;O.Q..,p4aMp14zta,,-will',-be-,disiibuied.inwater .bills; Line:wi)1';.be,added to High :Priority I.ine:list':resulting in _bi=
annual Oomihg.
PageA,

'Debrltlh 1rhe (Rb&§, sticks, t.!.Os and etc:).
WhafjypeW'do`bns:hasbeen fpUhd:i' the ,'l 'kqgs"
Suspec I ted I cause',or,sourmof debris- tegidefiti6l_:
Are.manholesi in the.area.seoure;ancf'intacf Yes: F.1 .No nNA D.NL'
When was the. area Ia8t,.'C'he6ked?cleane0 5452015-'
-T y
Have'cleaning and inspections ever.heen increased lgit this location, E M No� ONA, 1:1 NE.,
:due ,,.tb.prevnousz,probi'emsw' �..-it h debris?.
Are, appropri6to educational materials, being developed and disie6uted" k�'
K*'b§ :EJ )4.0 ONA, 0
to prevent future similar occurrences?,
:Q`omrnenis, F.O.6pbampl6is-vaill bedistribu&d im-wAter bills. Line Wi.1l.be..-.added t&tlioiPriorityline lisk., 'Cleafflng-of
lihe.V io4wiceianniall�;.
ill"be increased -u
Form CS-SS,Q Ngpo"A

.0ther,I-Pidures.'and police report, as app [cable,, must be--avail'ziblb upon regueA)
_ RNo - �NA
- �NE
' ^ rlNo -` - '

�,qfgql wsitator
QRQ
Name:.
'Adam UPM4
Certification Nomber: 996195'
Date visited. 2-16 201�5
Time visited: 4!10
'How was the -SSo remedlatbd Stoppedand -. 'cleaned . ,,up I
a
-and.-. unc�loggp4.?, M.6 waq44"q,-4around
no, wasjetted.
As a-represent6tive4brifie responsible. party: l ceit fv�thai,.the informaboh-c;ontaine�d iri.this-report ,,is true "gnd,attutat6,tothe:
bestof my knowledge:.
Person submitting 61aiiim, Maml-ipp
arty SJqnattire:� Title:
,
T j6046n6 number;
'7047992=`1415:1,
Any 04diti�boajjhfbrm' atio'hdi - iredjo bd-'submi d"should I te`spftt tq thehfive; business: days -of fiii knowledge of he.:SSO. with reference tq.the incident nLimberz (the incident number is only gpQqrad when,-e'lectr6n'ic,-.entry, offfiis,,f'brm is completed, itused):
T( orm "cq � , .-SSO

61
��m&A7�tal_l
Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# 000 .2' 5 Cf
Incident Number from BIMS 20150 12 4-
Incident Reviewed (Date):
Incident Action Taken: "BPJ
NOV-2015-DV
DV-2015-
m m m u m Room Sam 0 0 0 m m m m O m m m m m m m m m ROURM m m m am m m m m m m m m m 0 m ORURO am m m 0 0 MR an Dammam m I
Spill Date 1�12 3
Reported Date 9 �3 5
4.00 0"
Time 9?r / Om
Time 1 ��' �� am pm
Reported To SWP Staff or EM Staff l Pr L_ B de --
Reported By o r Phone
Address of Spill v �` a s S�✓ ..`� A
r
County �- l L City T� a`t,;,� ��+---
Cause of Spill
Total Estimated Gallons
S" O
Est. Gal to Stream 5
Stream '4 k-C c✓ , Fish Kill: Yes (T) Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad
0.r r yr ali + wa S G yn ol, �. 0� S n or af� .W_
s (. raft T 1 �e Gt ► ���G ✓s ✓� ! 1 M �m l S 0' �! ® S r s- a "4/
�Kr�75o ti �./i s
phC-,,1(

S-tat f6 . f t2ifAix
tnrat, Resources;
Dj stetResources;
. . . . . . . . . .
Collection DI-§afii Seve Overflow Reporting '9M
wislon of Water:lResoutr€:esForm CS
PAgTlt',
Tlhisf'orm!sh a'Wbe
: submitted
d-I �th,0 appr ploat WR eglonal.' po-within five businessdays,bfthe fist "knowledge o
sanitary seweT-overflow
(Z
Perryiit-_Ndmber "C866259 (WQWo"'E' otherwise -use 1NQGSD#)r
W
Facility:
`Region: MooresOfle .4"Tiputmaw Cou If'
Source ofsSbI(checkapocatilo Sanitary qqWpr EPu.p,$tStation JI Lift $.,tq#,!on
'S'POC 0 "si6rifindescription 4rom past repo or-documentitiorf,14eiRump
:
IFIC,"I cafion,offhe 8,80,�(be consireports
$tati6h 6,-Manhole , it vvestalt &:Bragg Stieet,;etc -Thomas SULOXW. right before,Ardial4hat crosses..MrAoiesMve.
L d" "ifiot Oc Longitude:
gitUde:Oegr6esknI
hutelsecor
46
t43taite! Time; 9 'IndOefifEfid, Ot 11725/15
(OMAO-yYyy): (h mrn)AM '*"AWPM
'Estimatedmat it U01 hours)
o'f,,'t-ha.S'�S'-'O� 1150-igallons i�iiied,'.' q(Op (roq!*ip"ri A0
bescIbe,hoW fhe.V Urne was determined e-­sf­m­.. aI-feq using approx flow r TOPli§d by )qqgffi;6f' me
Weafh il
dlq('Jqg_tlepSO PyqWdry
n' 90 F] Uhkhq
0141the ,
Iz
V01'ume-rLoad'hingsurface,�wat'ers:,So: gallons Surface` water names -3141cre&,
Did the Sq&rqpuif in a-A's-h :ki_1_11. EI'YeS 0 No .El.'Unknown
If'Y.'esj- what is . ti , mated number, offishkill'adl.'
8PE.C'IF,I'CjDauisq(s)...6fie,'S$O-,.
, R . 0 Elirifiow.'& 11 Itrat
Daevere Natural OohdiWns NJOrease. Ots, Cnfi 16-6
m Jjsji­­j_" Opio Failure I... 'k
tatiort Equipffi Failure TP, Vandalism
r6 ower'Oui4qe. ;Dvan alis Q 6b nJ ne-,P0a')'
24-b6W,verbal riotiftati6n (tiatN$ofpprsd .1":cd Barry'L'
OE qtgeh _ffijj�211S Ak/PM)y ,"
Ih-thedVeht" f- a--',d"s"ha-rob bf 1,,"0WgbI lonsi-.9-f-M-b-'r-e '91'Uhttetit6d MfeWdWtb'-the !§46c6w` t"- fifi ''S6 tat,'
prs,p p State*,
a press.zrdleaseI6 all.ptinf andelectronic news, media that,: I:co.verage� in; the: count provide genera y where, the
c d iA the details tfil-'A' ' h -d t1i 24 ti Affer
discharge: " ' ' - - The, Ohkii P�Js§'Uef,wji !in,'
argip� qqqyqe,:, sie Arglp� press
ifie°owneir or operafor has:d6ierrriine'dffi6't"t-he,'discharge has reached surface-waters..6f.the'.§ia
UIIIiEI HER OF PIOT Wtf 0 IS.:COMPL&EQ k=SIGkAtQiitt kt fIitb':.SEE '_'_PAGE I''
F6rm,C`S-S86'
Rage 1

Grease (Documentation such as:cleaning inspectionenfbrcement, actions, past overflow report' , educatfigngj
matedaf and distribution date -,:etc sh puld.5be available, -upon-,requ s.,;).
A'�orwe.wel�j.,'.was cleanetl' 1- 6 16 -
.Whenvas'fhe iaisffime ihit speafic-ine
Do You fipV6, an e46rcqa6lem g Rqqtkgtne requires new P grea$e0 Yet: fj`Nc' Ej, NA EJNE
ps/interceptors'?,
­ I- --- Updfipm a Have e- Ahb- r-e"pen recent t inspection -andt-o'-r"e'-n'f'ord6m"eti- bikehb- -h-
'n
near
rants-O.r.�,gt,ti,erhbnreeidetiiibl:gt66s6 dohtribbtd-s?
E31- 0 No El NE
Explain,
,
Have there: been other SI§O . s or blockaqm in Wis,preasiAhatwere also -Caused:
by.,grease Ej -yes No _E.ILWA ❑ NE
If yes;.describethem.
-Y "A Have dea6pq nd'inspections.ever been done 4-this location? :0, es LIP E.:1'NE
Exp
lain,
Havesducall'on4maiterial about'grease, been distributed in past?9;Yes 0 No ONA ZINE,
V'.V-hen: 8IM15-,
and ,towhomi.P H*
Explain:'Pamphl6is,were.handed;,oui>af-a,public -eveni,..•A—isoiiiformation.has.-been,in6luded,.inmdiliiig.s
itthe SS"O'-"occurred 'at-a.pump station, when was hew Oi well ap .4 pumps Iast.dl)eckdd,
for,grease accumulation:
Were the floats deahl ;:'yes11 No ONA NE
form lffS-986 Page 4,

System Visitatl6h
09C
Backupi Er y 1 4�9
'Nam a A
,C6itification Number 996195",
Tme;'Visited 9,ObAm
LAet" jjpsfqppeo, it was then cleaned isrng a zoos sew, and then tharoghl : Qushdd with a cteaaing nozzle Affected
d straw..
As a represontativ6-lbrifie r rAt6jb,,th&
b V,
6�fbf in 6wdbdLe.,
mi- A[ 'L—ipj .06rson:sub Adam pard.
Te( 0000 WOW.- 79+90Z-145:1
A ad fb­ 56wOW6�4 CO� 6" b- d' hd4ld
qy O#jOijal in 'Onal . kspoi e s,
, 4"khbVv'Wge,.,.-bf ' 6880 AW r6416rdn66
'f'fi
'b h di� --c!!
,�V� n:eledttonit-eritty,of.,this,Torm,is-�comp[died Ji'used) , ,.
tie„sent to the.`apPr`apnate Division. R io 11 4 - within five
pa Ofrj�e n
to the Jn- ideffi- t, {*ejftidi�ht number i only ly generated
-1--l-11-1— I'll. §-n I NO-1 -

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#
Incident Number from BIMS ;9,0 4� 06 (kelI
Incident Reviewed (Date):
Incident Action Taken
�IQ L IflIzo►I
B PJ
NOV-2008-DV
■ ■ a ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ a ■ ■ ■ a ■ ■ a a ■ ■ ■ ■ ■ a ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ m ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ a ■ ■ ■ ■ ■ ■ ■ ■ ■ 1
r.
Spill Date
Reported Date
Time "XI--k) amo
Time ��,` C� �pm
Reported To SWP Staff or EM Staff
Reported By Aa- I-X It , a4-f Phone
� ?
Address of Spill f0 w
County City
Cause of Spill
Total Estimated Gallons .WO Est. Gal to Stream _
Stream �„� ��//i%� Fish Kill: Yes No Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

v
C.3-16-12;09; 18AM;
704-528-7605
PO Box 26
Troutman, NC 28166
Phone: [phone]
Fax: [phone]
Fax
To: Barbara Sifford
DENR - Mooresville
Fax: [phone]
Phone: [phone]
RE: Form CS-SSO
Town of Troutman
From: Angela Hoover
Customer Service Representative
Date: March 16, 2012
Pages: 9 (including cover page)
CC:
URGENT FOR REVIEW PLEASE COMMENT PLEASE REPLY
COMMENTS:
Good Morning:
If you need anything else from us, please let me know.
Thank you
Angela H. Hoover Om&& A AjVW-
Customer Service Representative
Town of Troutman
PO Box 26
400 Eastway Drive
Troutman, NC 281.66
[e-mail]
Ph. 704.528.7600 Fax [phone]
PLEASE RECYCLE

03-16-12;09:18AM;
,704-528-7605 #r 2/ 9
Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
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: WQCS00258
Facility:
Owner: TOWN FO TROUTMAN
City: TROUTMAN, NC 28166
Source of SSO (check applicable)
(WQCS# if active, otherwise use treatment plant NCIWQ#)
0 Sanitary Sewer ❑ Pump Station
Incident #
Region:
06104" 1
MOORESVIL.LW
County: IREDELL
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.) : NEW STREET R.O.W
Latitude (degrees/minute/second):
Incident Started Dt: 03-12-2012
(mm-dd-yyyy)
:11
Estimated volume of the SSO:
Time- 7:44 pm
hh:mm AM/PM
Describe how the volume was determined:
gallons
VISUAL
PART 1
Lon gitude(deg rees/min ute/second)
Incident End Dt 03-12-2012 Time- 8:00 pm
(rhm-dd-yyyy) hh:mm AMIPM
Estimated Duration (Round to nearest hour
Weather conditions during SSO event, LIGHT RAIN
Did SSO reach surface waters? 0 Yes ❑ NoEJ Unknown Volume reaching surface waters (gallons): 300
Surface water name: 1.L. CREEK
Did the SSO result in a fish kill? ❑ Yes 0 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:
0 DWQ ❑ Emergency Mgmt.
0 Grease ❑ Roots
El Pump Station Equipment Failure ❑ Power outage
❑ Debris in Iine ❑ Other (Please explain in Part II)
TZ-V r hn M _ �X-70 re�,
Date (mm-dd-yyyy): 05-1'5- Z0J Z Time (hh:mm AMIPM): i LJ : UO Prn
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 uniess 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 11 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

063-16-12;09:18AM;
704-528-7605 * 3/ 9
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 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 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.
10/2011
❑Y.Z] No0NA❑NE
❑YJI No❑NA❑NE
Have there been other SSOs or blockages in this area that were also caused by grease? ❑YJZ No ❑NA ONE
When?
If yes, describe them:
Have cleaning and inspections ever been increased at this location? ❑Yes❑ No R NA ❑NE
Explain.
CS-SSO Form October 9, 2003 Page 2

03-16-12;09:18AM;
;704-528-7605 4/ 9
Have educational materials about grease been distributed in the past?
When?
and to whom?
❑YesO No❑NA❑NE
Explain?
If the SSO occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation? t—a
Were the floats clean? ❑ YesU No ®NA ❑ NE
Comments:
Roots
Do you have an active root control program?
Describe
®Yes[J NoElNA❑NE
Have cleaning and inspections ever been increased at this location because of roots? [:]Yes[:] No UNA ❑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 fine 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 EINA ONE
addresses Ill?
CS-SSO Form October 9, 2003 Page 3

03-16-12;09:18AM;
704-528-7605 # S/ 9
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 I/1 problems in the collection system at the SSO location? ❑Yes❑ No ❑NA ONE
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 ONA ONE
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? 11 Yes❑ No NA NE
If Yes, explain:
Have there been any grant or loan applications for 1/1 reduction projects? 11 Yes❑ NoD NA NE
If Yes, explain:
Do you suspect any major sources of inflow or cross connections with storm sewers? []Yes[] No ❑NA ONE
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) E]Yes
CS-SSO Form October 9, 2003 Page 4

03-16-12;09:18AM; ;704-528-7605
Audible ❑Yes
Visual ❑Yes
SCADA (two-way communication) E]Yes
Emergency Contact Signage ❑Yes
Other ❑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 Yes❑ No NA D 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 nun times prior to and during the SSO event? ❑Yes❑ No LJNA ONE
Were adequate spare parts on hand to fix the equipment (switch, fuse, valve, seal, etc.)? ❑Yes❑ No ❑ NA ❑ NE
Was a spare or portable pump immediately available? ❑Yes❑ No El NA El 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

C.3-16-12;09:18AM; ;704-528-7605 # 7/ 9
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-Site Generator
Did it function properly? ❑Yes No ❑NA ONE
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? 11 Yes❑ No ❑ NA U NE
If Vac h^%Ali
Padlocked Control Panel
Have there been previous problems with vandalism at the SSO location? 11 Yes❑ No NA ONE
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? —YeLJ No EINA NE
CS-SSO Form October 9, 2003 Page 6

03-16-12;09;18AM;
;704-528-7605 #, 8/ 9
When was the area last checked/cleaned?
Have cleaning and inspections ever been increased at this location due to previous problems with debris? 11Yes0 No ❑NA13NE
Explain:
Are appropriate educational materials being developed and distributed to prevent future similar ❑Yes❑ No ❑NA 11NE
occurrences?
Comments:
Other (Pictures and a police report should be available upon request.)
Describe:
Were adequate equipment and resources available to fix the problem? DYesO No❑NADNE
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: 1�1 �-1
DWQ Requested an Additional Written Report: 11YesO No ONA ❑NE
If Yes, What Additional Information is Needed:
Comments:
12
CS-SSO Form October 9, 2003 Page 7

l
O.3-16-12;09:18AM;
.704-628-7605 # 9/ 9
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:
Title:
Telephone Number:
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

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# 0c- �0 2S
Incident Number from BIMS
Incident Reviewed (Date): �Ce /Oq
Incident Action Taken: BPJ
NOV-2008-DV -- 00 '/'0
Spill Date f Time am/ pm
Reported Date f Time Ci am/ pm
(� Igrn
Reported To SWP Staff or EM Staff
0----)jFReport;�rBy
cl�(ct4dk_�- ' �hone
Address of Spill Oec,64(1 _X .2 4063—
County/�'(City I Ir6\4►'V1Ce�.��
Cause of Spill
,*MW
Total Estimated Gallons _ 6 (,C'% Est. Gal to Stream (000
Stream �rr:� '' Fish Kill: Yes No Number Sp c'es
u Non Rea uiredUnformation and other comments rela ing to SSO incident:
Response time minutes Zone Map Quad 160c

I
Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# 0615 9
Incident Number from BIMS 2b056) 4ifS
Incident Reviewed (Date):
Incident Action Taken: BpiVZ d
NOV-2007-DV -- 0 27 2-
0 ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ • ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ 1
Spill Date as / 3 T-S
Reported Date es i o-y
Time
.6, 35
am/ p(5
Time 0957 jr / pm
Reported To SWP Staff or<6 Staff / e,
Reported By l)avw SG./eeb" Phone 7oV-Sag-7600
Address of Spill _I&A" &Aj/ 4 1.23 41405,bn e0re, � e ���s�n �/e�� 4/x
5 ` d"L.,4b�j
County City
Cause of Spill
Total Estimated Gallons Est. Gal to Stream 366
Stream./ .il-A _7-L, OrocA Fish Kill: Ye<Dumber Species,
Non Required Information and other comments relating to 330 incident:
Response time minutes Zone Map Quad
7-A Oak

Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
PART
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'. C5 OV 5 0 (WQCS# if active, otherwise use treatment plant NCIWQ#)
Facility: � � Incident #
Owner: Of n Region: Mao V� GI
City: County: G(
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 Stati n 6,
Manhole at Westall &Bragg Street, etc.) : Ma.1/JHol2 bekWY�' 12,3 AddIS04 PlaCfo — tQ5 rcn laclAhfs Subdiv
Latitude (degrees/minute/second):
IncidentStarted Dt:O OS Time:
(mm-dd-yyyy) sr. hh:gM/ °As�.�",
Estimated volume of the SSO: v 0mm w .J gallons
, n
Longitude(degrees/minute/second)
Incident End Dt �` f 3 g Time:
(mm-dd-yyyy) hh:mm AM/PM
Estimated Duration (Round to nearest hour); 3 5 him
Describe how the volume was determined: '`" vt4 0 "'w "` — I •"`r_l "'""'
Weather conditions during SSO eV
nt:
6 vhn G 5v (kind
Did SSO reach surface waters? Yes ❑Non Unknown Volume reaching surface waters (gallons): Soo
Surface water name: Wou)n (PNK &htrld 1,23 Addvs'm PlA_`e i F/oWr
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
❑ Inflow and Infiltration ❑ Pump Station Equipment Failure ❑
❑ Vandalism 0 Debris in line ❑
Immediate 24-hour verbal notification reported to:
DWQ ❑ Emergency Mgmt.
I
Roots
Power outage
Other (Please explain in Part II)
Date (mm-dd.-yyyy): U✓!- �q,09 Time (hh:mm AM M): Oq5—,7
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 If 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?
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.
❑YeSE] NoDNA11NE
[]Yes[:] No DNA®NE
Have there been other SSOs or blockages in this area that were also caused by grease? ❑Yen No ❑NA ❑NE
When?
If yes, describe them:
Have cleaning and inspections ever been increased at this location? ❑Yen No DNA11NE
Explain.
CS-SSO Form October 9, 2003 Page 2

Have educational materials about grease been distributed in the past?
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 Floats clean?
Comments:
❑Yes❑ No❑NA❑NE
❑Yeso No ❑ NA ❑ NE
Roots
Do you have an active root control program? oYeE No ❑ NA ❑ NE
Describe
Gl���� i *e5 avrd cvf gao f5 �wt c pee v,�
Have cleaning and inspections ever been increased at this location because of roots? ❑Ye No ❑NA❑NE
Explain:
What corrective actions have been accomplished at the SSO location (and surrounding system if
associated with the SSO);
h a� veGlLInp- � VI"P- 2do ` -��
What corrective actions are planned at the SSO location to reduce root intrusion?
Lint V1deaed - i!�n�e /s 5,c4Ptl,�,/le Insp-p-oltail-clES?K14C4 I'l �&dm!�
Has the line been smoke tested or videoed within the past year? ❑YeA 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 UYes® No ❑NA B 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? ❑YesC No ❑NA ONE
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? 11Ye0 No ❑ NA ❑NE
If Yes, explain:
Have there been any grant or loan applications for 1/1 reduction projects? Yes No DNAEINE
If Yes, explain:
Do you suspect any major sources of inflow or cross connections with storm sewers? ®Yes[] No ❑NAUNE
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream been inspected recently? ®YesD 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

Audible Elyes
Visual ❑Yes
SCADA (two-way communication) ❑Yes
Emergency Contact Signage ❑Yes
Other ❑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? []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
11YesE] WEINA❑NE
1Ye50 No❑NA❑NE
DYes❑ 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? ❑YeLl 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?
LU Yes❑ No ❑ NA ❑ NE
If Vac hn{el?
Padlocked Control Panel
Have there been previous problems with vandalism at the SSO location? YesEINo ❑NA NE
If Yes, explain:
What security measures have been put in place to prevent similar occurrences in the future? Dyes[] 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 NA NE
CS-SSO Form October 9, 2003 Page 6

When was the area last checked/cleaned?
Have cleaning and inspections ever been increased at this location due to previous problems with debris? ❑YesE1No ❑NA ❑NE
Explain:
Are appropriate educational materials being developed and distributed to prevent future similar ❑Yes❑ 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? ❑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:
LJ 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 this report is true and accurate
to the best of my knowledge.
Person submitting claim:
Signature:
Telephone Number:
Date:
Title:
ik
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

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# /
Incident Number from BIMS Zob� U i 1
Incident Reviewed (Date): D*J 2
Incident Action Taken. Bpi
NOV-2007-DV
Spill Date d e� d� Time
3-1/S
am/"@)
Reported Date Time g m, pm
Reported To SWP Staff or EM Staff
Reported B b /C
p y �`�� Qa�-,e.✓ Phone �o�- �32-377r°C .
Address of Spill 9/ 3 1117/! ,-b-1< �o
County /i/f,� City
Cause'of Spill V%jkAAj-1i a-s -� y�4-
Total Estimated Gallons 3`f
Est. Gal to Stream 34
Stream C00,42-L Fish Kill: Ye 5Number .Species
Non Required Information and other comments relating to SSO incident:
Response time 4S minutes Zone Map Quad
C

Permit #
Owner and Facility Name
WQCS00253
Bradfield Farms Water Company Collection System
WQCS00196
Carolina Water Service Cabarrus Woods Collection System
WQCS00233
Carolina Water Service Hemby Acres Collection System
WQCS00001
Charlotte -Mecklenburg Collection System
WQCS00016
City of Albemarle Collection System
WQCS00046
City of Belmont Collection System ,
WQCS00107
City of Bessemer City Collection System
WQCS00089
City of Cherryville Collection System
WQCS00221
City of Claremont Collection System
WQCS00326
City of Concord Collection System
WQCS00088
City of Conover Collection System
WQCS00017
City of Gastonia Collection System
WQCS00020
City of Hickory Collection System
WQCS00327
City of Kannapolis Collection System
WQCS00036
City of Kings Mountain Collection System
WQCS00040
City of Lincolnton Collection System
WQCS00164
City of Lowell Collection System
WQCS00026
City of Monroe Collection System
WQCS00059
City of Mount Holly Collection System
WQCS00044
City of Newton Collection System
WQCS00019
City of Salisbury Collection System
WQCS00037
City of Shelby Collection System
WQCS00030
City of Statesville* Collection System
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 Collection System
WQCSD0117 Duke Energy Carolinas LLC-Marshall Steam Station
WQCSD0116 Goose Creek Utility Company -Fairfield Plantation WWTP
WQCSDO101 Harborside Dev LLC-Midtown T Collection System
WQCSDO095 Kennerly Dev. Group LLC-Boardwalk Villas Condo. Collection Systerr
WQCSDO098 Kennerly Dev. Group LLC-Kings Point Collection System
WQCSDO105 Kennerly Dev. Group LLC-Moon Bay Condos Collection System
WQCSD0107 Kennerly Dev. Group LLC-Schooner Bay Collection System
WQCSDO099 Kennerly Dev. Group LLC-Spinnaker Point Collection System
WQCSD0112 Lake Norman -South Point Collection System
WQCSDO104 Lake Norman -Villas S Harbour Collection System
WQCSDO102 Lake Norman -Vineyard Pt Resort Collection System
WQCSDO064 Lincoln County Collection System
WQCSDO097 Martin Dev Group -North Point & Portside HOA Collection System
WQCSDO120 Martin Marietta Materials Inc - Mallard Creek
WQCSDO019 Richfield Town Collection System
WQCSDO024 Town of Grover Collection System
WQCSDO038 Town of McAdenville Collection System
WQCSD0002 Town of Ranlo Collection System
WQCSDO049 Town of Spencer Mountain Collection System
Permit #
Owner and Facility Name
WQCS00149
East Lincoln Collection System
WQCS00171
Greater Badin Collection System
WQCS00322
Aqua Country Woods East CS
WQCS00222
Town of Boiling Springs CS
WQCS00341
Town of China Grove CS
WQCS00231
Town of Cleveland Collection System
WOCS00058
Town of Cramerton Collection System
WQCS00165
Town of Dallas Collection System
WQCS00342
Town of E. Spencer Collection System
WQCS00328
Town of Harrisburg Collection System
WQCS00343
Town of Landis Collection System
WQCS00310
Town of Longview Collection System
WQCS00120
Town of Maiden Collection System
WQCS00344
Town of Marshville Collection System
WQCS00043
Town of Mooresville Collection System
WQCS00125
Town of Mt Pleasant Collection System
WQCS00153
Town of Norwood Collection System
WQCS00190
Town of Oakboro Collection System
WQCS00325
Town of Stanfield Collection System
WQCS00180
Town of Stanley Collection System
WQCS00135
Town of Taylorsville Collection System
WQCS00258
Town of Troutman Collection System
WQCS00345
Town of Wingate Collection System
WQCS00054
Union County Collection System '
WQCS00009
WSA Cabarrus Co. Collection System

I
Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# ©C, a
Incident Number from BIMS
Incident Reviewed (Date)
Incident Action Taken
.�� BP
NOV-2008-DV
5aaaaa0a03aa0a2s0aa0120aae0aaaaaa90¢9eaaaaaa5aaa0aacae5aaaaaac2a00aa2aaa1
Spill Date t-L l I Time am/ pm
Reported Date 12 C�ro Time �'� �� am/ pm
Reported T� Staff or EM Staff
Reported ByPhone
Address of Spill
County 1�_C, city
Cause of Spill1—
Total Estimated Gallons 'I to-,
Est. Gal to Stream --
Stream — Fish Kill: Yes Q Number Species
Non Required Information and other comments relating to SSO incident:
Response time , minutes Zone Map Quad

14
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
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
WQCS00030
City of Statesville 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
WQCSD0116
Goose 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
WOCS00322
Aqua Country Woods East CS
WQCS00222
Town of Boiling Springs CS
WQCS00341
Town of China Grove CS
WQCS00231
Town of Cleveland CS
WQC.S00058
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
WQCSDO064
Lincoln County CS
WQCSDO097
Martin Dev Gp-N Point & Portside CS
WQCSDO120
Martin Marietta Mallard Creek
WQCSDO019
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
WQCSD0252 All spills which do not have a permit
number assigned

r..
1 9
of VdAr�A
D v � rl8 Form CS-SSO
o Collection System Sanitary Sewer Overflow Reporting Form
14 PART
This form shall be submitted to the appropriate DWQ 'a1;O.ffce within;five daysof the afft knowledge of
the sanitary sewer overflow (SSO). �` ` `"'" ' `` `C"k. li
Permit Number: 0 a 6 00 o? 6 p (WQCS# if active, otherwise use treatment plant NC/WQ#) '?
Facility: a Incident #
4d wo OO,eQSYG e
Owner: � Region: r
City:? 0 a!� County: 1,ee�,o//
Source of SSO (check applicable) : ❑ Sanitary Sewer U� Pump Station
SPECIFIC location of the SSO (be consistent jp cjgscrjptigq from past repp is or docui
Manhole at Westall & Bragg Street, etc.) :
Latitude (degrees/minute/second)-
Incident Started Dt//
: 12 r ( &�'T Time- �v 0
(mm-dd-yyyy) I hh:mm AM
Estimated volume of the SSO: /o2100 gallons,
Describe how the volume was determined: " ' " C.-
Weather conditions during SSO event: d 1
Did SSO reach surface waters? ❑ Yes wNo ❑ Unknown
Surface water name:
Did the SSO result in a fish kill?
- i.e. Pump Station 6,
Long itude(degrees/minute/second)
Incident End D - /O? 1 112E Time-
(mm-dd-yyyy) hh:mm AM
Estimated Duration (Round to nearest hour); � S
5
Volume reaching surface waters (gallons):
❑ Yes allo ❑ Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
❑ Severe Natural Condition ElGrease ❑ Roots
MInflow and Infiltration ❑ Pump Station Equipment Failure ❑ Power outage
❑ Vandalism ® Debris in line ❑ Other (Please explain in Part II)
ImEediate 24-hour verbal notification reported to: Loy, �o ����
DWQ ❑ Emergency Mgmt. Date (mm-dd-yyyy): �g Time (hh:mm AM/ . �'
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 ere t e ischarge 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; o
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of th.b 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

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? Yesu No ❑NA ❑NE
If Yes, when was the study completed and what actions did it recommend?, c�0061'266'/ I i- S{udy cti9fvl'ol-ew b y
Famew 6- mlji-ewi l9 , 55maoholes 4nd .2 &14"m h 045 to c ommewdod L'e g!!E
Has the line been smoke tested or vid ed within the past year? R�WYesLJ No LINA LINE
�lonomtcs �cun �cl&ned Rr4' "Ae- Avi�eo/�ihPS1n ./4y4e 6cl mvePe- a®a7,
If Yes, when and indicate what actions are necessary and the status of such actions: o4ke r;{g(41446'l PS e'Aed11eW
�Vm d de et a e d o din c dip lz a/f�2 In
Are there 1/1 related projects in your Capital Improvement Plan? Yes❑ No NA1:1 NE
� 1man ho l p-s sd edo l 102 �pt�v�Pvi� %► Zoo Y
If Yes, explain: r gjjmp S¢t4revi ( (-edae Ln.) 5CA-edvA4d 99- 0014 m"v
Have there been any grant or loan applications for 1/1 reduction projects? Ye . No NA NE
If Yes, explain:
Do you suspect any major sources of inflow or cross connections with storm sewers? 0YeV 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 act* are planned to prevent future 1/1 related SSOs at this location?
� 6k4dduai!<ecAg&4
Comments:
Station
be orov
What kind of notification/alarm systems are present?
Of
Auto-dialer/telemetry (one-way communication)
—Wau (OMMUliif•
etc.
5het'5&t1-
OYes
CS-SSO Form October 9, 2003 f - I Page 4

Audible (OYes
Visual [ Yes
SCADA (two-way communication) ❑Yes
rull
Emergency Contact Signage les
Other ElYes
Describe the equipment that failed?
11
Cj1rChae4,t due Aaw pain PumU i& oo collYna, t-am oA WAA ldll
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?Yell 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:
jWYes3 No ONA ❑ NE
OYesu No ONA ❑NE
JjYesO NO0NADNE
❑YesW No O NA D NE
CS-SSO Form October 9, 2003 Page 5

When was the area last checked/cleaned?
Have cleaning and inspections ever been increased at this location due to previous problems with debris? 0Ye,0 No DNA ❑NE
Explain:
Are appropriate educational materials being developed and distributed to prevent future similar ❑YesO W 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[--] No0NA13NE
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:
OYZ No DNA❑NE
CS-SSO Form October 9, 2003 Page 7

rotative for the res
information contained in this re
Person submitting claim: Date: Y
Signature: 1%%141! � T✓�,�...,
Title:
Telephone Number: 7r/f' SLfl 7L�
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

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#
Incident Number from BIMS
Incident Reviewed (Date): /
Incident Action Taken: BPJ
NOV-2008-DV
■ ■ ■ a ! a ■ ■ ■ a ■ ■ ■ ■ a a ■ ■ ■ ■ ■ a ■ a a ■ ■ ■ ■ 6 ■ ■ ■ ■ ■ a ■ a a Is ■ ■ a ■ ■ a ■ ■ ■ ■ 6 a ■ a a ■ ■ ■ ■ ■ a a ■ ■ ■ a ■ a a ■ ■ ■ 1
Spill Date �-Z Time
Reported Date Z,Z- Time
Reported To 32�b Staff or EM Staff
N,2.cD am/ 0
'3`.am/6
Reported By Phone
Address of Spill (.As_-
-
County �Ccc- City r1 t
Cause of Spill
Total Estimated Gallons ISOC-)
Stream
Est. Gal to Stream -
Fish Kill: Yes C Do Number Species
Non Required Information and other comments relating to SSO incident:
Response time -- minutes Zone Map Quad

Permit #
Owner and Facility Name
Permit #
Owner and Facility Name
WQCS00253
Bradfield Farms Water Company CS
WQCS00171
Greater Badin CS
WQCS00196
Carolina Water Service Cabarrus Woods CS
WQCS00322
Aqua Country Woods East CS
WQCS00233
Carolina Water Service Hemby Acres CS
WQCS00222
Town of Boiling Springs CS
WQCS00001
Charlotte -Mecklenburg CS
WQCS00341
Town of China Grove CS
WQCS00016
City of Albemarle CS
WQCS00231
Town of Cleveland CS
WQCS00046
City of Belmont CS
WQCS00058
Town of Cramerton CS
WQCS00107
City of Bessemer City CS
WQCS00165
Town of Dallas CS
WQCS00089
City of Cherryville CS
WQCS00342
Town of E. Spencer CS
WOCS00221
City of Claremont CS
WQCS00328
Town of Harrisburg CS
WQCS00326
City of Concord CS
WQCS00343
Town of Landis CS
WQCS00088
City of Conover CS
WQCS00310
Town of Longview CS
WQCS00017
City of Gastonia CS
WQCS00120
Town of Maiden CS
WQCS00020
City of Hickory CS
WQCS00344
Town of Marshville CS
WQCS00327
City of Kannapolis CS
WQCS00043
Town of Mooresville CS
WQCS00036
City of Kings Mountain CS
WOCS00125
Town of Mt Pleasant CS
WQCS00040
City of Lincolnton CS
WQCS00153
Town of Norwood CS
WQCS00164
City of Lowell CS
WQCS00190
Town of Oakboro CS
WQCS00026
City of Monroe CS
WQCS00325
Town of Stanfield CS
WQCS00059
City of Mount Holly CS
WQCS00180
Town of Stanley CS
WQCS00044
City of Newton CS
WQCS00135
Town of Taylorsville CS
WQCS00019
City of Salisbury CS
WQCS00258
Town of Troutman CS
WQCS00037
City of Shelby CS
WQCS00345
Town of Wingate CS
WQCS00030
City of Statesville CS
WQCS00054
Union County CS
WOCS00149
East Lincoln CS
WQCS00009
WSA Cabarrus Co. CS
Deemed Permitted
Permit #
Owner and Facility Name
WQCSDO130
Brooks Food Group -Brooks Food Group
WQCSD0114
Charlotte Mecklenburg Schools - Misc Laterals
WQCSD0057
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
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
WQCSDO064
Lincoln County CS
WQCSDO097
Martin Dev Gp-N Point & Portside CS
WQCSDO120
Martin Marietta Mallard Creek
WQCSDO019
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
WQCSD0252 All spills which do not have a permit
number assigned

is
Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
PART
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: WC 00o?5 (WQCS# if active, otherwise use treatment plant NCMQ#
Facility: Incident #
Owner: `l. Ti-� oo a Region: Amus
City: County:
Source of SSO (check applicable) : VY Sanitary Sewer ❑ Pump Station
SPECIFIC location of the SSO (be consistent in descry*ptionblo,
om past r�jports r documentation - i.e. Pump Station 6,
Manhole at Westall & Bragg Street, etc.) : MAI �1f91� A I ii I) 1 � / C f dja4 L h
Latitude (degrees/minute/second):
Incident Started Dt: Time:
(mm-dd-yyyy) hh:mm AM
Estimated volume of the SSO: ��1 galloons
Describe how the volume was determined: " hs e etl -P
Weather conditions during SSO event:
Did SSO reach surface waters? 11 Yes XNo Unknown
Surface water name:
Longitude(degrees/minute second):
Incident End Dt-�a Time:
(mm-dd-yyyy) hh:mm AM
Estimated Duration (Round to nearest hours a
B
Volume reaching surface waters (gallons):
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
FMSevere Natural Condition ElGrease ❑
VM Inflow and Infiltration ❑ Pump Station Equipment Failure ❑
11 Vandalism ❑ Debris in line /❑
Im ediate 24-hour verbal notification reported to: `on 5rt, ldf-p-
rVI
DWQ ❑ Emergency Mgmt. Date (mm-dd-yyyy): �� d
Roots
Power outage
Other (Please explain in Part II)
Time (hh:mm AM 'y. 8 o
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

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? 11 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 Plans Yes❑ No ❑ NA ❑ NE
5 Manhole5 ee scheduled/0 zV ,fef#6edi,* -2ob 9
e2 S,fchors e4ping is ! 'ekdvl�s( /V 6�e 04;'e
amed;" 2 � t
If Yes, explain:Ceoe lance RPMP 5{�kew /s 5chedv/ec6 �'e�/aCe�te�'G� « �x5; / Qv glee
.,_„1".
Have there been any grant or loan applications for 1/1 reduction projects?
If Yes, explain:
No LJNA U NE
Do you suspect any major sources of inflow or cross connections with storm sewers? ❑YesK No ❑NA ❑NE
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream been inspected recently? []Yes[] No MNA LINE
If Yes, explain:
What other corrective actions are planned to prevent future 1/1 related SSOs at this location?
Comments: (U+1d uldeO 'E'ct f -�
Pump Station Equipment Failure (Documentation of testing, records etc.
shoul be provided upon request.)
What kind of notification/alarm systems are present? 54glSoii
Auto-dialer/telemetry (one-way communication) OYes
olee(e55 od f (one-way e®lvrnvkwt{aki) �.echhod®y
CS-SSO Form October 9, 2003 Page 4

Audible MYes
Visual Yes
SCADA (two-way communication) ❑Yes
Emergency Contact Signage XYes
Other ❑Yes
Describe the equipment that failed?
5u04Chaiem due k Aewy Rain - pomp ;5QtoeL 6ovPd Aa-f P-.eQp q wWA cnNW4
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 [INA ❑ NE
Did any pump show above normal run times prior to and during the SSO event? AYes❑ No ❑NA ONE
Were adequate spare parts on hand to fix the equipment (switch, fuse, valve, seal, etc.)? AYes❑ No ❑ NA DNE
Was a spare or portable pump immediately available? DYerd
pj 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

t ' '0 f
When was the area last checked/cleaned?
Have cleaning and inspections ever been increased at this location due to previous problems with debris? ❑Yes❑ No IJNA ❑NE
Explain:
Are appropriate educational materials being developed and distributed to prevent future similar 11Yes0 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: 13Yes❑ No ❑NA El NE
If Yes, What Additional Information is Needed:
Comments:
CS-SSO Form October 9, 2003 Page 7

f f ., 1 � .- 11 y
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: �,r- TV /0• S,dLF�J
Date: / Z >Q 0, r
Signature: Title: „ '0WA-4 !7±22 ' �d,,,�",►✓
Telephone Number: Ter
Any additional information desired to be submitted should be sent to the appropriate Qivision 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

"W�
Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# 56
Incident Number from BIMS
Incident Reviewed (Date):
Incident Action Taken
BPJ
L �NOV-200-DV
S-7
Spill Date r/ AC Time M VC am pm
Reported Date —402 Time pm
Reported To SWP Staff or EM Staff �
Reported By 9WC/ 6Ln(� ScA3 Phone rJO-
Address of Spill
County
Cause of Spill
City
Total Estimated Gallons /Ur Est. Gal to Stream
Stream Fish Kill: Yes No Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

_�co� VdYiTF9Q�
Form CS-SSO
>_ Collection System Sanitary Sewer Overflow Reporting Form
o �
PART
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: L' S oQ a 5 0
�eO 0 t_ �a� (WQCS# if active, otherwise use treatment plant NC/WQ#) -
Facility. Incident #
Owner: TOW� �� ' Region:
City: 7-6 W ;4 0-F TIe0C'+Ma14- County: TeedP.i�
Source of SSO (check applicable) : Sanitary Sewer ❑ Pump Station
SPECIFIC location of the SSO (be consistent in des ription from past reports or documentation - i.e. Pump Station 6,
Manhole at Westall & Bragg Street, etc.) : �'� 3 11h ROt) le gusset/ S1.. PumP f-(-ahod
Latitude (degrees/minute/second):
Incident Started Dt: 0 l Aq Time: /0 ' /5 6n
(mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: �' 00G) gallons
A 1 n A
Describe how the volume was determined:
Weather conditions during SSO event: �tihh
Did SSO reach surface waters? Yes ❑ No ❑ Uhknown
Surface water name:
Did the SSO result in a fish kill? L._I Yes 0No ❑ Unknown
SPECIFIC cause(s) of the SSO:
❑ Severe Natural Condition
❑ Inflow and Infiltration
Vandalism
S
Pmediate 24-hour verbal notification reported to:
DWQ ❑ Emergency Mgmt.
Longitude(degrees/minute/second)
Incident End D , lik -'00Time- 0 ' ✓ R`Yf
(mm-dd-yyyy) hh:mm AM/PM
Estimated Duration (Round to nearest hour)- 020
r17 o r
Volume reaching surface waters (gallons):
If Yes, what is the estimated number of fish killed?
❑ Grease ❑ Roots
❑ Pump Station Equipment Failure ❑ Power outage
Debris in line ❑ Other (Please explain in Part II)
Base bmea S5,46 i
Date (mm-dd-yyyy):%r o? .4200q Time (hh:mm AM/PM): 11:1Q a-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 remiss 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 bf 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

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-Site Generator MATS
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 Voc hn%en
Padlocked Control Panel
Have there been previous problems with vandalism at the SSO location?
If Yes, explain:
[]Yes[-] No❑NA❑NE
Not81NA LINE
What security measures have been put in place to prevent similar occurrences in the future? 11YesE1 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?
T (e(C(0-tk
How could it have gotten there?
lhe-ee a' aaues 4 64- 110 ev,
CS-SSO Form October 9, 2003
Page 6

When was 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:
b,
Are appropriate educational materials being developed and distributed to prevent future similar UYesLI No
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:
13YesU No❑NA13NE
CS-SSO Form October 9, 2003 Page 7
lle4'

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:
Signature:
Telephone Number:
Date: / _Z16,- o %
Title:
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

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#���
Incident Number from BIMS c - Zet-1 &-0
Incident Reviewed (Date):
Incident Action Taken: BPJ
�/NOV-200' DVCS �7
DV-2008-
Spill Date Time d � am/ m
Reported D to rA-7 G Time a pm
Reported. To SWP Staff or EM Staff
Reported By01�f`z5 Phone
Address of Spill <53 9 0-&XaT
CountyCity
Cause of Spill
Total Estimated Gallons D Est. Gal to Stream��
Stream (&CAWILFish Kill: Yes No Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

r= -W
N \b r Po
AForm CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
45
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 : 0 0.26 (WQCS# if active, otherwise use treatment plant NC/WQ#)
Facility:leoof Incident #
Owner: T6 co VL O7�Uf dcl a,K Region: �Moo"
.61/C `G
City: County:���
Source of SSO (check applicable) : Sanitary Sewer ❑ Pump Station
SPECIFIC location of the SSO (be consistent in description from past repgrts r do umen ation - i.e. Pump Station 6,
Manhole at Westall & Bragg Street, etc.) : 1W 12o ho%Pi IOC�Lw2ft IM 3 cf 8 Leen h ie-M roa&�4
Latitude (degrees/minute/second): Long itude(degrees/minute/second):
Incident Started Dt.. °20� Time: /-V:� ow Incident End Dt�l a � eLa Time:
(mm-dd-yyyy) hhh::mm AM/PM (mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: gallons gallons Estimated Duration (Round to nearest hour
Describe how the volume was determined: " �5 A/�,� oU � -mce_ llmalm
Weather conditions during SSO eve t:
Did SSO reach surface waters? LU Yes ❑ o❑ Unknown Volume reaching surface waters
^n g (gallons): DQ
Surface water name:
Did the SSO result in a fish kill? ❑ Yes allo ❑ 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
yam+` Vandalism Debris in/line ❑ Other (Please explain in Part 11)
LAIm ediate 24-hour verbal notification reported to: �" � /�the tp Q e [Eeg
DWQ ❑ Emergency M mt. Date mm-dd- 9 Y 9 ( YYYY):OI o?'% o?QOG Time (hh:mm AM/PM): `� . 5D G�•�??.
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

Power outage (Documentation of testing, records, etc., should be
provided of alternative power source upon request.)
What is your alternate power or pumping source?
'On -Site Generator w/ATS
Did it function.properly? Yes] NoF—INAONE
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 Vcc hrmt?
Padlocked Control Panel
Have there been previous problems with vandalism at the SSO location?
If Yes, explain:
[]YesU NO❑NADNE
No UNA U NE
What security measures have been put in place to prevent similar occurrences in the future? DYes13 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?
Cto�-f�WO 11AW 1,9P-P1,404 r.),PI<
How could it have gotten there?
KO GJ �-�@V►1 (wG l�.y 5f
WI&P G
CS-SSO Form
MA
October 9, 2003
of
we5-� Ime. 1P15pq5?r*°q'.
Page 6

-V
When was the area last checked/cleaned?
Have cleaning and inspections ever been increased at this location due to previous problems with debris? 0Ye No CINA ❑NE
Explain:
Are appropriate educational materials being developed and distributed to prevent future similar 11Yes[] No EINA ❑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 (INA CIN E
CS-SSO Form October 9, 2003 Page 7

e , '-r
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: ��v�0 . Sig L �C6'c� Date: -- Z—D
Signature: 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

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#
Incident Number from BIMS
Incident Reviewed (Date):
Incident Action Taken: i&E3gPJ
NOV-2009-DV
i [ • ... . . . .,.. . . ... . .. . ... . . . . . . . .. . . . .. . ... . . . . . . .... . . . ■ . . ■ . . . . ... ....... .
Spill Date �'� 'Z Time go/ Pm
Reported Date r 2 Time �-� � Pm
Reported To Staff or EM Staff L 5
Reported ByPhone
Address of Spill C�
CountyCityr�'��
Cause of Spill Te,6r; ;j-77
SO
Total Estimated Gallons Est. Gal to Stream 0
Stream JKV IL Vs , L Fish Kill: Yes r Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map. Quad

Permit #
Owner and Facility Name
Permit #
Owner and Facility Name ,
WOCS00253
Bradfield Farms Water Company CS
WQCS00171
Greater. Badin CS
VVQCS00196
Carolina Water Service Cabarrus Woods CS
WQCS00322
Aqua Country Woods East CS
WOCS00233
Carolina Water Service Hemby Acres CS
WOCS00222
Town of Boiling Springs CS
WOCS00001
Charlotte-1-0ecklenburg CS
VVQCS00341
Town of China Grove CS
WQCS00016
City of Albemarle CS
WQCS00231
Town of Cleveland CS
WQCS00046
City of Belmont CS
WOCS00058
Town of Cramerion CS
WQCS00107 '
City of Bessemer City CS
WQCS00165
Town of Dallas CS
VJQC-..Snnn89..
C..;t nf r.hprNvine C..S
_ ._WQCS00221..•__Ciiy
o[Clarempnl•,CS._.._...__.__...._. _ __............. _.........
--.__.WQCS00328--•Town of Harrisburg .CS..- -- — — -- - -7-
WQCS00326
City of Concord CS
WQCS00343
Town of Landis CS
WQCS00088
City of Conover CS
VVQCS00310
Town of Longview CS
WQCS00017
City of Gastonia CS.
VVQCS00120
Town of Maiden CS
WQCS00020
City of Hickory CS
WOCS00344
Town of Marshville CS
1NQCS00327
City of Kannapolis CS
WQCS00043
Town of Mooresville CS
WOCS00036
City of Kings Mounlain CS
WQCSD0125
Town of fOt Pleasant CS
WQCS0004D
City of Lincolnlon CS
WOCS00153
Town of Norwood CS
WOCS00164
City of Lowell CS
WQCS00190
Town of Oakboro CS
WQCS00026
City of Monroe CS
WOCS00325
-Town of -Stanfield CS
WOCS00059
City of Mount Holly CS
WOCS00160
Town of Stanley.CS
WQCS00044
City of Newton CS
WQCS00135
Town of Taylorsville CS
WQCSOD019
City of Salisbury CS-
WOCS00258
Town of Troutman CS
WQCS00037
City of Shelby CS
WQCS00345
Town of Wingate CS
1NQCS00030
City of Statesville CS-
WQCS00054
Union County CS
WQC•S00149
East Lincoln CS
WQCS00009
WSA Cabarrus Co. CS
Deemed Permitted
Permit#
Owner and Facility Name
Permif# -
Owner and Facility Name
WQCSD0130
Brooks Food Group -Brooks Food Group
WQCSD0064
Lincoln County CS
VVQCSD0114
Charlotte Mecklenburg Schools - Misc Laterals
WQCSD0097
Martin Dev Gp-N Point 8 Portside CS
WOCSDOD57
City of High Shoals CS
WQCSD0120
Martin Marietta Mallard.Creek.
WOCSDO117
Duke Energy Marshall Steam Station
VVQCSD0019
Town of Richfield CS
WQCSD0257
Fallslon
WQCSDO024
Town of Grover CS
WOCSD0116
Goose Creek Utilities Fairfield Planlation VA T P
V\rQCSD0038
Town of McAdenville CS
1NQCSD0101
Harborside Dev.LLC-Midtown T CS
WQCSD0002
Town.of Ranlo CS
1NQCSDDD95
Kennerly Dev. Group LLC-Boardwalk Villas CS
WQCSD0049
Town of Spencer Mountain CS
WQCSDD098
Kennerly Dev. Group LLC-Kings Point CS
., WQCSDO105
Kennerly Dev. Group LLC-Moon Bay Condos CS
WQCSD0252
All spills which do not have a'permit
number assigned
WQCSD0107
Kennerly Dev. Group LL C-Schooner Bay CS
WQCSD0099
Kennerly Dev. Group LLC-Spinnaker Point CS
WQCSD0258
Kinosiown
INQCSD0ii2
Lake Norn-,an-Soul`: Point CS
VdQCS'DC104
Lake Nlorman'Villas S Harbour CS
'NOOSDO102
Lake NoG^an-Vinevard Pf Resor CS

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: WACS00258 (WQCS# if active, otherwise use treatment plant NC/WQ#.) _
Facility: TROUTMAN Incident # [
Owner:
TOWN OF TROUTMAN Region: MOORESVILLE
City: TROUTMAN, NC County: IREDELL
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.) : Manhole between West Ave & Winchester Ave
Latitude (degrees/minute/second): Longitude(degrees/minute/second):
Incident Started Dt: 10-02-2009 Time: 9:30 am Incident End Dt.10-02-2009 Time: 10:15 am
(mm-dd-yyyy) hh:mm AM/PM (mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: 650 gallons Estimated Duration (Round to nearest hour
Describe how the volume was determined: Very small flow from two homes
Weather conditions during SSO event: cloudy -dry
Did SSO reach surface waters? 0 Yes ❑ No ❑ Unknown Volume reaching surface waters (gallons): 650
Surface water name: Mackey Creek
Did the SSO result in a fish kill? ❑ Yes R1 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:
0 DWQ ❑ Emergency Mgmt.
El
Grease
❑
Pump Station Equipment Failure
E
Debris in line
Lon Synder
Date (mm-dd-yyyy): 10-02-2009
❑ Roots
ElPower outage
El Other (Please explain in Part II)
Time (hh:mm AM/PM): 10:25 am
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

The Town is presently rehabilitating an older section of its collection system. Part of this work involves
the re -lining of sewer lines. The lines upstream from the SSO were being worked on and before the line
was relined, the contractor cleaned the lines. Most of the debris from the cleaning process was
vacuumed and disposed of properly. Some of the debris found its way down stream and settled in a
part of the collection system that we had the SSO in.

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❑NE
If Vac hnte0
Padlocked Control Panel
Have there been previous problems with vandalism at the SSO location? ❑Yes❑ No NA ENE
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?
Towels, underweare, roots grease
How could it have gotten there?
The town is presently rehabilitating an older section of its collection system. Part of this work involves the re-liningletthe sewer lines. The lines up stream from the SSO were being worked on and before the line was relined, the
contractor cleaned the lines. Most of the debris from the cleaning process was vacuumed and disposed of properly. Some of the debris found its war down stream and settled in a part of the collection system that we had the SSO in.
Are manholes in the area secure and intact? VYesU No UNA LINE
CS-SSO Form October 9, 2003 Page 6

When was the area last checked/cleaned?
2nd Qtr 2009
Have cleaning and inspections ever been increased at this location due to previous problems with debris? ❑Yes❑✓ No ❑NA ❑ NE
Explain:
Not needed due to the reason started.
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 UNE
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: �I
DWQ Requested an Additional Written Report: UYes❑ No ❑NA 11 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: T 4 L o S 4 l 6451JA/
Signature:
Telephone Number:
Date: /® /Q 9
Title: 6a.A ��' 22�
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

WorkCentre 7345
Transmission Report
G3 ID 704-528-7605
Local Name Town Of Troutman
Logo
Document has been sent.
Document Size 8.5X11"SEF
PO Box 26
Troutman, NC 28166
Phone: [phone]
Fax: [phone]
Fax
Date/Time:10/05/2009;10:48AM
Page: 1 (Last Page)
To: Lon Snyder From: David Saleeby
Troutman Town Manager
Fax: [phone] Date: 5 October2009
Phone:[phone] Pages: 6 (Indudingcover page)
RE: SSO CC:
URGENT FOR REVIEW PLEASE COMMENT PLEASE REPLY PLEASE RECYCLE
COMMENTS:
In addition to the SSO, I have attached a copy of the explanation for "Now could It have gotten there?"
on page six of the SSO, because It is so long it is very small print and may be difficult to read.
Total Pages Scanned: 6 Total Pages Sent 6
No. Doc. Remote Station Start Time Duration Pages Mode
Contents Status
1 8371 7046636040 10- 5;10:46AM 1m57s 6/ 6 G3 CP
Note:
RE: Resend MB: Send to Mailbox BC: Broadcast MP: Multi Polling RV: Remote Service
PG: Polling RB: Relay Broadcast RS: Relay Send BF: Box Fax Forward CP: Completed
SA: Send Again EN: Engaged AS: Auto Send TM: Terminated

nwn nf Trr
PO Box 26�
Troutman, NC 28166
Phone: [phone]
Fax: [phone]
Fax
To: Lon Snyder From: David Saleeby
Troutman Town Manager
Fax: [phone] Date: 5 October 2009
Phone: [phone] Pages: 6 (including cover page)
RE: SSO CC:
URGENT
COMMENTS:
FOR REVIEW PLEASE COMMENT PLEASE REPLY PLEASE RECYCLE
In addition to the SSO, I have attached a copy of the explanation for "How could it have gotten there?"
on page six of the SSO, because it is so long it is very small print and may be difficult to read.

RE.CEIVED
VJ Jt
.I g Form CS-SSO
Collection Sys`t�nnII rtii Slagit ry Sewer Overflow Reporting Form
.MRO PART IMC,, ��
This form shall be submitted to the appropriate DWQ Re tonal Offlcr with' iv da softhe�Vst knowledge of
the sanitary sewer overflow (SSO). DWQ-fit,(` ..y, x..si`tns ?4ion
Permit Number: WOC' S 00258 (WQCS# if active, otherwise use treatment plant NC/WQ#)
Facility: Troutman Incident# a00006/4Ps
Owner: `1 nwn of 'Trniitman Region: MnnrPavi 11.P
City: Town of Troutman County: Iredell
Source of 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 Westall & Bragg Street, etc.) : C'Priar T anP SPwPr ROW Manhnl P # S
Latitude (degrees/minute/second): Long itude(degrees/minute/second)
Incident Started Dt: 01 / 15 / 0 8 Time. 2 : 3 0 pm Incident End Dt: 01 / 15 / 0 8 Time. 4 : 4 5 pm
(mm-dd-yyyy) hh:mm AM/PM (mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: 600 gallons Estimated Duration (Round to nearest hour`. 2 hrs.
Describe how the volume was determined: Observed flow over time involed.
Weather conditions during SSO event: Sunny/ 42 ° 'Light Wind
Did SSO reach surface waters? ® Yes ❑ No ❑ Unknown Volume reaching surface waters (gallons): 6 0 0
Surfacewater-name:R' g Rranrh of ui r--kG Creek — Catawba River Basin
Did the SSO result in a fish kill? ❑ Yes [n No ❑ Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
❑ Severe Natural Condition ❑ Grease ❑X Roots
El 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: Barbara S i f f ord
0 DWQ ❑ Emergency Mgmt. Date (mm-dd-yyyy): 01 / 16 / 0 8 Time (hh:mm AM/PM): 8 : 5 0 am
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

w<<r�,�4G
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?
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 ❑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

Have educational materials about grease been distributed in the past? ❑Yes❑ No ❑ NA ❑ NE
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? I-1
Were the floats clean? ❑Yes❑ No ❑ NA ❑ NE
Comments: 1
Roots
Do you have an active root control program?
Describe
usYes❑ No❑NA❑NE
We jet and cut roots twice per year
Have cleaning and inspections ever been increased at this location because of roots? ❑YesAXNo ❑NA ❑NE
Explain:
What corrective actions have been accomplished at the SSO location (and surrounding system if
associated with the SSO)?
LiuLiue was � ef-t ed and rnnts ^jt.
What corrective actions are planned at the SSO location to reduce root intrusion?
Line was videoeA. Line is scheduled to be inspected in (6) six months.
Has the line been smoke tested or videoed within the past year? ❑YeP 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 121NE
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 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

Audible
Visual
SCADA (two-way communication)
Emergency Contact Signage
Other
Describe the equipment that failed?
Elyes
❑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 ❑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 fix the equipment (switch, fuse, valve, seal, etc.)? ❑YesE1 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 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?
•■Ge-terator
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? 1 DYes❑ No ❑ NA D NE
If Vac hnw?
Padlocked Control Panel
Have there been previous problems with vandalism at the SSO location?
If Yes,.explain:
No IJNA LJNE
What security measures have been put in place to prevent similar occurrences in the future? []Yes[] No ❑ NA D NE
Comments:
Debris in line (Rocks, sticks, rags and other items not allowed in the
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 NA NE
CS-SSO Form October 9, 2003 Page 6

When was 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:
11Yes❑ No ❑NA11NE
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:
Signature:
Date:
//�-a9
Title:
Telephone Number: �D sZ g 7`Qd
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

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#
Incident Number from BIMS
Incident Reviewed (Date):
Incident Action Taken: V BPJ
NOV-2012-DV
I m r r ®r r r m m m r m m r r r m r r m m r r■ REDEEM MUM m r m r m m M r r r r m r r m m r m m r r r r 9 m m m m r 8 m r 9 m MEMO
Spill Date `f Time C 1& pm of
Reported Date I` 3 Time pm
Reported To SWP Staff or EM Staff
Reported ByPhone
Address of Spill P14,4rs0tv f�;-4 ;ro
County City Mil
Cause of Spill
sA_01K
Total Estimated Gallons t6 00 Est. Gal to Stream 300
Stream Fish Kill: Yes (S Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

t •,
0 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: VV V` 002
(WQCS# if active, otherwise use treatment plant NCMQ#)
Facility: li VtU(kg.- Q4 Incident# p "')-01j4o0 /Gl
Owner: ic�u;N of tc�tlhUu� Region:
City: ab Wt Nl6N _ - County: ked, i f
Source of SSO (check applicable) : ❑ Sanitary Sewer IJ 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.) :- EIJI, VltIQ4e Zt+4. jk-4'oA;:
Latitude (degrees/minute/second):
Longitude(degrees/minute/second)
Incident Started Dt: 4122 1 ZC lj Time- It'. 30a m Incident End Dt W2'- I Time- /i ev'
(mm-dd-yyyy) hh:mm AM/PM (mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: 5° o° gallons Estimated Duration (Round to nearest hour). �' S
Describe how the volume was determined: 'AMC' N� 01Ped' (Lf 19'e-W0 US L440-HtA
Weather conditions during SSO event -
Did
Did SSO reach surface waters? U Yes❑No❑ Unknown Volume reaching surface waters (gallons):
Surface water name:
Did the SSO result in a fish kill? ❑ Yes ❑ No 1 I Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
❑ Severe Natural Condition El Grease ❑ Roots
El Inflow and Infiltration uX Pump Station Equipment Failure ❑ Power outage
11 Vandalism ❑ Debris in line ❑ Other (Please explain in Part II)
Immediate 24-hour verbal notification reported to:
❑ 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 scharge 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

QF.1Ntir�r�
�p Form CS-SSO
-- Collection System Sanitary Sewer Overflow Reporting Form
PART 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?
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.
uYes❑ No❑NA❑NE
❑ YekNo ❑ NA ❑ NE
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? 11 YX No ❑NA❑NE
Explain.
3wck
CS-SSO Form October 9, 2003 Page 2

. Have educational materials about grease been distributed in the past?
EfYes❑ No ❑ NA ❑ NE
When? t'► ACLN� ZO 1 3
and to whom?
Explain? ��a� d Oct aNAUAIJ
If the SSO occurred at a pump station, when was the wet well and pumps last checked for grease upkA►o W'0
accumulation?
Were the floats clean?
Comments: �LLNS 04 1`p- &ryr'2SSlu-2
Roots
Do you have an active root control program?
Describe
UYes❑ No❑NA❑NE
I / -1 No❑NA❑NE
Have cleaning and inspections ever been increased at this location because of roots? []YesffNo ❑NA [:]NE
Explain:
What corrective actions have been accomplished at the SSO location (and surrounding system if
associated with the SSO)? , gvd',,Aj„ oN (4)
What corrective actions are planned at the SSO Vocation 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 ❑YesL:.J No ❑NA ONE
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`? Nof 1 £� kloks
Has there been any flow studies to determine 1/1 problems in the collection system at the SSO location? L° i YesU No UNA U NE
5rl,h5 20(- .
If Yes, when was the study completed and what actions did it recommend? tl c 1A' u N Cb& t' (40C 4pp.,,- v &
Has the line been smoke tested or videoed within the past year? 11 Ye No ®NA UNE
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 11 NA❑NE
If Yes, explain:
Have there been any grant or loan applications for 1/1 reduction projects? Yes171
J-1 No ❑NA ®NE
If Yes, explain:
Do you suspect any major sources of inflow or cross connections with storm sewers? rizo No EINAUNE
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream been inspected recently? ®Yes[] No ❑NAUNE
If Yes, explain: Ted (vqc, Cpt+ &O N6 1
J Re=X e_ 5a tv
What other corrective actions are planned to prevent future I/I related SSOs at this location?
Comments:
Puma Station Eauioment Failure (Documentation of testing. records etc.
shoul be provided upon request.) _
What kind of notification/alarm systems are present? J�OE�W�e�_ i`ghF
�2z2!
Auto-dialer/telemetry (one-way communication)
Iles
CS-SSO Form October 9, 2003 Page 4

Audible
Visual
SCADA (two-way communication)
Emergency Contact Signage
Other S-(.U^CS6f�
Describe the equipment that failed? JN'D N'b T
�es
Yes
❑Yes
❑Yes
LJYes
What kind of situations trigger an alarm condition. at this station (i.e. pump failure, power failure, high
water, etc.)? A I � m F 0- ty6VE
Were notification/alarm systems operable? 614/jkZ22f ,Mca� SAC-41CA Ye No❑NAE1NE
If no, explain: AOet`' 41Cn
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?
I
If an auto -dialer or SCADA, when was the system last tested? How?
I�ss t ors cep !!bL Vis11
Comments:
1JYesD No❑NAONE
❑ Yes0No ❑ NA ❑ NE
@YeSO No ❑ NA ❑ NE
YesZJ'No ❑ NA ❑ NE
CS-SSO Form October 9, 2003 Page 5

Power outage (Documentation of testing, records, etc., should be
What is your alternate power or pumping source?
•n-Site Generator
Did it function properly? ❑YesE] No'LTNA❑NE
N/A �dW 6AP- CAI st(f P-ML djiCa_ C, Ls.Q0_IC/leX2f'ca5rt
Describe?
When was the alternate power or pumping source last tested under load? g
If caused by a weather event, how much advance warning did you have and what actions were taken to
prepare for the event?
hI
Comments:
Vandalism
Provide police report number: NI'A
Was the site secured? ❑ Yes❑ No ❑ NA ❑ NE
If Yoc he%%W?
Padlocked Control Panel
Have there been previous problems with vandalism at the SSO location?
If Yes, explain:
N/fl
No
What security measures have been put in place to prevent similar occurrences in the future? ❑Yes❑ No ❑ NA El NE
Comments: IA
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 NA NE
CS-SSO Form October 9, 2003 Page 6

,When was the area last checked/cleaned? WE
Have cleaning and inspections ever been increased at this location due to previous problems with debris? []YeNo ❑NA ❑ NE
Explain:
Are appropriate educational materials being developed and distributed to prevent future similar El Yes[] No ❑NA LINE
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: �I
DWQ Requested an Additional Written Report: QYeNo ❑NA LINE
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:
Signature: ` 211a92� Title:
Telephone Number:
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

Sifford, Barbara
From: Adam Lippard <[e-mail]>
Sent: Wednesday, April 23, 2014 5:42 PM
To: Angela Hoover, Sifford, Barbara
Cc: Ann Bailie
Subject: Re: Town of Troutman
Barbara, the creek is an un named tributary the feeds to IL Creek. Let me know if you need anything else.
Thanks,
Adam
Sent from my iPhone
On Apr 23, 2014, at 3:00 PM, "Adam Lippard" <[e-mail]> wrote:
Barbara, we had an issue with our floats at Streamwood Pump Station and it wasn't triggering our
pumps to come on. We went to check a low water alarm and found it to be close to the top of the wet
well. This station has a very large wet well (40 ft deep) and one of our technicians turned the pumps to
hand to get it pumped down and overwhelmed a smaller station that this one pumps to. That is where
the spill occurred. The floats were replaced today and we had an electrician look over the controls and
everything is at 100% again. I am trying to find out the name of the water sourced it spilled into. I will
let you know ASAP when I find something out.
Thank you,
Adam Lippard
Town of Troutman
Public Works Manager
Office # - 704-528-7616
Cell # - 704-902-145'
Eph. 6:10-20
Email correspondence to and from this address is subjuct to North Carolina Public Records Law and may be
disclosed to third parties unless the content is exempt by statute or other regulation.
From: Angela Hoover
Sent: Tuesday, April 22, 2014 4:37 PM
To: Sifford, Barbara
Cc: Adam Lippard; Angela Hoover
Subject: RE: Town of Troutman
Ms. Sifford
I am forwarding this to Adam so he can get that information for you.
Sincerely,
1

Angela Hoover
Accounting Technician
Town of Troutman
PO Box 26
400 Eastway Drive
Troutman, NC 28166
[e-mail]
Ph. 704.528.7600 Fax [phone]
"Email correspondence to and from this address is subject to the North Carolina Public Records
Law and may be disclosed to third parties unless the content is exempt by statute or other
regulation"
From: Sifford, Barbara [mailto:barbara.siffordCcbncdenr.gov]
Sent: Tuesday, April 22, 2014 4:35 PM
To: Angela Hoover
Subject: RE: Town of Troutman
Got the report, I am unclear on a few items, the pump station failed but what exactly failed. Pumps or
controls? Do you know the surface water this would drain to, besides the Catawba River. Adam can
call me tomorrow.
From: Angela Hoover [mailto:ahoover(a)townoftroutman.org]
Sent: Tuesday, April 22, 2014 4:23 PM
To: Sifford, Barbara
Cc: Angela Hoover; Adam Lippard; Randy Galliher
Subject: SSO: Town of Troutman
Ms. Sifford:
Attached is an SSO for the Town of Troutman (permit # WQCS00258). Please let me know if
there is anything else that needs to be done.
Thank you,
Sincerely,
Angela Hoover
Accounting Technician
Town of Troutman
PO Box 26
400 Eastway Drive
Troutman, NC 28166
2

[e-mail]
Ph. 704.528.7600 Fax [phone]
"Email correspondence to and from tills address is subject to the North Carolina Public Records
Law and may be disclosed to third parties unless the content is exempt by statute or other
regulation"