WQCS00325_Regional Office Historical File Pre 2018

Collection System SSO 24-Flour Notification
Collection System: Number and Name WQCS#
Incident Number from BIMS 20150
Incident Reviewed (Date):
Incident Action Taken: BPJ
NOV-2015-DV
DV-2015-
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Spill Date �! �� lug Time 7'�� am/ pm 1 �m
Reported Date . ( Time �1.t Dy 6m-) pm
Repotted To &�taff or EM Staff
orted By
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Kdd ress of Spill
County City
Cause of.Spill
Total Estimated Gallons :55,U1) 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
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SEP-15-2015 14:40 From: To:7046636040 Pase:1-'2
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Pipe Failure (Break)
Pipe size (inches)
What is the pipe material Pj L°
What is the approximate age of the line/ pipe (years old)
Is this a gravity line?
Is this a force main line?
is the line a "High Priority" line?
Last inspection date and findings
If a force main then,
Was the break on the force main vertical?
Was the break on the force main horizontal?
❑ Yes X No ❑NA ❑ NE
A Yes ❑ No ❑NA ❑ NE
DKYes ❑ No ❑NA ❑ NE
❑ Yes No ❑NA
Yes ❑ No DNA
Was the leak at the joint due to gasket failure ? ❑ Yes No ❑NA
Was the leak at the joint due to split bell? ❑ Yes No ❑NA
When was the last inspection or test of the nearest air -release valve to determine if operable? When was was the last maintenance of the air release performed?`/�
If gravity sewer then,
Does the line receive flow from a force main immediately upstream ❑ Yes No [:]NA
of the failed section of pipe?
If yes, what measures are taken to control the hydrogen sulfide production?
When was the line last inspected or videoed?
❑ NE
❑ NE
❑ NE
❑ NE
❑ NE
If line collapsed, what is the condition of the line up and down stream of the failure? /V/A
What type of repair was made? 15 e'u /^e-�A91rr Sle—e &G
�wu
If temporary, when is the permanent repair planned?
Have there been other failures of this line In the past five years? ❑ Yes K No DNA ® NE
If so, then describe
Form CS-SSO Page 12

SEP-15-2015 14:41 From: To:7046636040 Pa9e:2/2
1 .
System Visitation
ORC
Backup
NYes
❑ Yes
Name: �r4riti��� S
Certification Number; J01q
Date visited" Cr /10 /15
Time visited:
How was the SSO remediated (i./e. Stopped and cleaned p)? �� �° �¢ S f-rC9
t.964S ` R Ma's e d y 44/d PN'" P'e � �t�.�.�t i
re-Ac�,.; way cre e-k .
As a representative for the resoonsible party. I certifv that the information contained in this report is t[u n accurate to the
best of my knowle
Person submitting Claim:
Signature:
Telephone Number:
Date,
Title:
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