NC0089656_Report_20210819

DWR
Division of Water Resources
Incident Report
Report Number : 202101795
Incident Type : Bypass
Category Incident
Incident Started : 06/15/2021
Country : Mecklenburg
City: Charlotte
Farm #:
Responsible Party :
Owner : DC Charlotte Plaza LIIp
Permit : NC0089656
Facility : Dimensional Place
First Name : Tim
Middle Name :
Last Name : Hendricks
Address : 1515 S Tryon St
City/State/Zip : Charlotte NC 28203
Phone :
On -Site Contact :
First/Mid/Last Name :
Company Name :
Phone :
Pager/Mobile Phone :
/
Reported By :
First/Mid/Last Name : Christopher David Orrell
Company Name :
Address :
City/State/Zip :
Phone :
Page/Mobile Phone :
/
Material Category: Estimated Qty: UOM: Chemical Name Reportable Qty.lbs. Reportable Qty.kgs.
Latitude :
Longtitude :
DD:MM:SS Decimal
Position Method :
Position Accuracy :
Position Datum :
Location of Incident : 1515 S. Tryon St. Charlotte, NC 28203
Address :
City/State/Zip : Charlotte
Report Created
8/19/21 12:38 pm
Page 1

Cause/Observation : Directions :
Action Taken :
Incident Questions :
Comments :
Did the Material reach the surface Water? No Conveyance :
Surface Water Name ?
Did the Spill result in a Fish Kill? No Estimated Number of fish? 0
If the Spill was from a storage tank indicate type •
Containment? Unknown
Cleanup Complete? Unknown
(Above Ground or Under Ground)
Water Supply Wells within 1500ft : Unknown Groundwater Impacted :Unknown
Pump Station
Eauioment Failure
Event Type Event Date Due Date Comment
Report Entered 2021/08/19 11:56:58
SSO 24-hr Reported start 2021/06/15 3:41:00
Report Received 2021/06/15 3:41:00
Referred to Regional Office - Primary Contact 2021/06/15 3:41:00
Report Created
8/19/21 12:38 pm
Page 2

Standard Agencies Notified :
Agency Name Phone First Name M.I. Last Name Contact Date
Other Agencies Notified :
Agency Name Phone First Name M.I. Last Name Contact Date
DWQ Information :
Phone:
Date/Time:
Referred Via:
Report Taken By:
Report Entered By: Regional Contact:
Edward Watson Edward Watson Edward Watson
2021/06/15 03:41:OOPM
Did DWQ request an additional written report?
If yes, What additional information is needed?
2021/08/19 11:56:58AM 2021/06/15 03:41:OOPM
Report Created 8/19/21 12:38 pm Page 3