NC0035904_Facility Update_20031227

12/29/2003 14:39 910-944-1759
MEDICAL RECORD DEPT
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Sewage Spi 1 response -Evaluation:
(Page 1)
Permitee c. ' �. Penni Number IQ C.- 003%7%4- County FL k.—
Incident Started: (Date/Time) '1 cCV1-51ncident Ended: (DateTrme)- I1/2-7/03/ / l 3 S
If spill is ongoing, please notify Rjlonal Office on a daily basis until spill can be alp • ped,
z, a 1,4.0
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weather conditions: '041- t*1 cal I,,, 91-0 Q 6F
Source of spill/bypass (check one): Sanitary Sewer
Level of treatment (check one):
Estimated volume of spill/bypass
Reported to: "az F4Aq, RevOateitime)
Pump Station _ WWTP
None Primary Treatment
—1/4k Secondary Treatment Chlorination Only
10. 0.1)0 gallons. Show calculations.
b' ha- aCQa.S Lit. p1 of '1'a 91 etreao t A
Did spill/bypass reach surface waters?
Volume reaching surface waters?
Name of surface water
Did spill/bypass result in a tish kill?
If Yes, what is the estimated number of fish k ed?
Yes No (If Yes, please list the following)
N)fA
Please provide the following Information:
1. Location pf spill/bypass' C
aeons
Cisa3s�.o4
2- Cause of spill/byp ms: 4'A P „ e ; Cq I COS wi, 4
V' a tki cki 110 erka, *o 11-0. e el 11,, ttki
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3: Did you have personnel available to perfori initial assessment 24 hours/day (including weekend
holidays)?
Yes No
4. How long did it take to make an initial assessment of the spill/o rfow after first knowledge?
• Hours t4a Minutes (Din ro�.�a,^
How long did it take to et a repair crew orriite?
- Hours V® Minutes
Pipasq explaintthe the m e initial sessrrient
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and
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12/-29/2003 14:39
Permitee
910-944-1759 MEDICAL RECORD DEPT PAGE 03
Sewage -Spill Response Evaluation:
(?age 2)
PAEr Kt.0 'CZ,5, Pe' lit Number t\./C-th3Sa_04- county li ke_Ccv,V I`
5. Action taken to contain spill, glean up wate, andlor
remediate the site:
6. Were the equipment and parts needed t: make repairs readily available?
Yes `j( , No If no, please axi lain why:
7. If the spill/overflow occurred at a pump :-ation, or was the result of a pump station failure,
was the alarm system functional at the t le of the spill? Yes No If the alarm
system did not function, please explain Iiy: ,
/J
B. Repairs made are: Permanent \A Temporary
Please describe what repairs were made If the repairs are temporary, please indicate a date
which permanent repairs will be cornplel d, and notify the Regional Office within 7 days or the
permanent repair.
9. Wnat actions have b -n made to p -vent his discharge from •curing again in the future?
1, 11 bQl W/ 3 t
s. Comments:
y
Other agencies notifed: Oe CrO,�(t GTt 3 - Ce a/o. l ,oritoeermi
Person report! •ill/byp- s: d 7 COrr,, ""''""[�v"" /�Phone Number: ((D
Ch� 2 CKWwL �S
1 \
Sicnature �' a 03
Date:
For DWQ Use Only:
DWQ requested additional written report? . Yes No
If yes, what additional information is needec
Requested by

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•12{29/2003 14:39 910-944-1759
MCCAIN CORRECTIONAL- HOSPITAL
855 Old NC 211, Raeford, North Carolina 28376
Phone: [phone] ' Fax: [phone]
a3(
601-06.. Ow
Phone:
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