NCS000331_SSO_20210517

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Spill Incident Report Form
Facility: Incident#
Owner: Old North Utility Services, Inc. Region: Fayetteville Regional Office
City: County:
Source of SSO Sanitary Sewer Pump Station
Specific Location of SSO (example: Lift Station # 1, manhole at Westall & Bragg, etc)
Incident Start Date: Time:
AM or PM
Incident End Date: Time:
AM or PM
Estimated Duration rounded to the nearest hour
hour(s)
Estimated volume of the SSO gallons
Did SSO reach surface waters? Yes No
Volume reaching surface water gallons
Surface Water Name Did the SSO result in a fish kill?
If so, what is the estimated number of fish killed?
Specific Cause of the SSO:
Natural Disaster Grease
Roots
Inflow & Infiltration Pump Station Equip Failure
_Power Outage
Vandilism Debris in Line
Other
Explaination:
Immediate 24-hour verbal notification reported to:
(Name)
DWQ Emergency Management
Date: Time: AM or PM
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Last revision 112012015