WQCS00110_BIMS Report_20220316 (2)

State of North Carolina
Department of Em>ironrnental Quality
Mision of Rater Resources
f Collection System Sand my Sew cr Overflow Reporting Fdriah
`Division of Water Resources Form CS-SSO
PART C
This form shall be submitted to the appropriate DWR Regional Office within five business days of the first knowledge of the
sanitary sewer overflow (SSO).
Permit Number. WdGSj0O I f0 (WQCS# if active, otherwise use WQCSD#)
Facility: 706jAu Ur- eUY7-on1 Incident #:.202200 V/D Owriker % k/n/ d/' C(Jf y%o-J
Region: MILEI(.14 City: CLAYiO--/ County: 1 cAWJ o J
Source of SSO (check applicable): 21 Sanitary Sewer ❑ Pump Station / Lift 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.): #,VA4LLGr 041 �¢,(�s�jE✓� R 7 rlli9y2E CE�c
Manhole #: M U14 -A S-0 9 ,(>F6AG y
Latitude (degrees/minute/second): 35" bN 313 Longitude (degreestminutelsec ond): - 78. SY62O0
Incident Started Dt: a-?-/7-.eb22 Time: QZ&9 401 Incident End Dt: 3 /?-,22 Tune: &&7,40f
(mm-dd-yyyy) (hh:mm) AM/PM (mm-dd-yyyy) (hh:mm) AWPM
Estimated volume ofthe SSO: /.1%,30D gallons Estimated Duration (rotund to nearest hour):-1'6' hour(s)
Describe how the volume was determined: F10- x 2- 57-iA-11 7416W e2d -j y /,(!,( ,' e&-- AIP,S"1,gt4V 6w
Weather conditions during the SSO event ,e4/Al I/ L e&V ✓
Did fie SSO reach surface waters? (�r Yes ❑ No ❑ Unknown
Volume reaching surface waters- 544100 gallons Surface water name:
Did the SSO result in a fish Will? ❑ Yes ❑ No R Unknown
If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
®Severe Natural Conditions ❑ Grease
❑Pump Station Equipment Failure ❑ Power Outage
Other (Please explain in Part 11)
❑Roots ❑ Inflow & Infiltration
❑Vandalism ❑ Debris in lime []Pipe Failure (Break)
24-hour verbal notification (name of person contacted): /y%9RY,IW41 /v/tGL/aYlE�
❑Dll1/R Emergency Management Date (mm-dd-yyy): D /7 2'Z Tune: (hh:mm AM1PM):
Per G.S_ 143 215.1 C(b), the owner or operator of any wastewater collection system shall
In the event of a discharge of 1,000 gallons or more of untreated wastewater to the surface waters of the State, issue
a press release to all print and electronic news media that provide general coverage in the county where the
discharge occurred setting out the details of the discharge_ The press release shall be issued within 24 hours after
the owner or operator has determined that the discharge has reached surface waters of the State_
In the event of a discharge of 15,000 gallons or more of untreated wastewater to the surface waters of the State,
publish a notice of the discharge in a newspaper having general circulation in the county in which the discharge
occurs and in each county downstream from the point of discharge that is significantly affected by the discharge. The
Regional Office shall determine which counties are significantly affected by the discharge and shall approve the form
and content of the notice and the newspapers in which the notice is published_
WHETHER OF NOT PART 11 IS COMPLETED, A SIGNATURE IS REQUIRED SEE PAGE 13
Form CS-SSO Page 1

In order to submit a claim for justification of an SSO, you must use Part II of form CS-SSO with additional documentation as
necessary. DWR staff will review the justification claim and determine if enforcement action is appropriate.
PART II:
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 SECTONS 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 DWR REGIONAL OFFICE UNLESS
IS HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Form CS-SSO Page 2

Severe Natural Conditions (hurricane tornado etc.)
Describe the "severe natural condition" in detail: /�� �
_6rs/r/ /6W &IttalMl
la /e&! 419 alsf11A2 .( Al6aiZW�I I, 74(e— /(¢/W vr-- 4�� iWO-
How much advance waming did you have and what actions were taken in preparation for the event? /Uavi"
Comments:
IM
Form CS-SSO Page 3

Grease (Documentation such as cleaning insaection erdercerneM actions, past overflow reports. educational
material and diistnbution date etc should be available upmi reQuest_�
When was the Past tirree this specffic fine (or wet vveff) was cleaned?
Do you have art enforceable grease ordinance that requires new or retrofvt of
grease traWinterceptors? ❑ Yes ❑ No ❑ NA ❑ NE
Have there been recent inspection and/or enforcement actions taken on near-
by restaurants or other nonresidential grease contributors? Yes No ❑ ❑ NA ❑ NE
L-w "
have there been other SSOs or blockages in this areas that were also caused
by gas ❑ Yes ❑ No ❑NA ❑ NE
When?
If yes, describe them:
Have cleaning and inspections ever been done at this location?
Explain.
Have educational material about grease been distributed in the past?
❑ Yes ❑ No DNA ❑ NE
❑ Yes ❑ No ❑NA ❑ NE
Explain:
If the SSO occurred at a pump station, when was the wet well and pumps last d wcked for grease accumulation:
Were the floats mean?
Comments:
❑ Yes ❑ No DNA ❑ NE
Form CS-SSO
Page 4

Other (Pictures and police report as applicable must be available upon request.)
Describe:
Were adequate equipment and resources available to fix the problem? QrYes ❑ No ❑NA ❑ NE
If Yes, explain: C�/7'rC¢l%OL L/ /00 f4"oWeW i-' OWco 4 DAM 4102� 'f /Viy ,1 . ;Si
/✓ �% j�L /qG �i�. w� G�LLC/O /N S� Y!%/L �Q[KR'1 0 `12a A�pd �rJ /i9 LOtJ.
If the problem could not be immediately repaired, what actions( Yes ❑ No ❑NA ❑ NE
were taken to lessen the impact of the SSO?
Comments:
Oat A*,"I—1 '%4f ,Q[L 4/41fJ $Y1'a,ur"::7 CWIIOr G �,r ro
/N7o �y�,��EAr�c,e w�L� ;WY",P6�7y ��.c i,✓/G�� w,�it�
AW
pd Flor.�r�� 411ZV IAb 70 7he- two w97C# abv oeo /,3Y r, cow. , �� i/K-
,y/6a AIEV,—�L 444/16f h-2 07"Al• 2 AlWa
Catn/�-
y,/1 fJN L`X�Ug�/L %/fc G�J�2Fl.O�✓/NG ti1h� 9(Vd &/L% %� t�4�1 S'r/X2o�/biyt
A<L 6 P✓ lgqbW En�7 /.�G 7XIF
GwcL= 7/fc� �b,rl,G4G?vim C� /7-'/J l'vIVi°s
444"1AP dJ &,V/ 44/o
Form CS-SSO Page 11

pipe Fai,Iiure (Break).
Pipe size Carncl es),:
Mat is the, pipe : raaater-eAt
What is the a{p{ mem ele age of the Nine! pipe (years otd):
is this a gravity Nne?
❑ Yes ❑ No
❑NA
❑ NE
Ns this a force main line?
❑ Yes ❑ No
❑NA
❑ NE
Is the line a "'High PrioW Lane?
❑ Yes ❑ No
[]NA
❑ NE
(Last inspection date old findings
If a force maim then,
Was the break on the farce main vertical?
❑ Yes ❑ No
❑NA
❑ NE
Was the break on the force main horizontal?
❑ Yes ❑ No
❑NA
❑ NE
Was the leak at the rri due to gasket failure ?
❑ Yes ❑ No
❑NA
❑ NE
Was the leak at the FwA due to split tom?
❑ Yes ❑ No
[]NA
❑ NE
When was the Iasi 'tirmpection or test of the nearest air -release valve to detem'ine if operable?
When was the Iasi mawdenance of the an release performed?
If gravity sewwer then,
Does the time receuwe flow from a force main immediately upstream ❑ Yes ❑ No []NA ❑ NE
of the failed section of pipe?
If yes, what measures are taken to control the hydrogen sulfide production?
When was the line Iasi irspecled or videoed?
K line collapsed, what is the cDnddmn of the lineup and downstream of the failure?
What type of repair was made?
tt temporary, when is the permanent repair planned?
Have there been other falures of this line in the past five years?
h so, then describe
❑ Yes ❑ No ❑NA ❑ NE
Form CS-SSO Page 12

System Visitation
ORC WYes ❑ No
Backup ❑ Yes ❑ No
Name:—1/{i11tS &4404j4
Certification Number. _ADO'ZO.2/
Date visited: , 3-1,7-?D.2 /
Time visited: 4 ,�Y'07WPI
How was the SSO remediated (i./e. Stopped and cleaned up)?
P4teEo /*awo odE�['ow�^/� N61 v ,s>vp rFiow /•✓�o
col 4a+' �oA- w vs/NG w1-7& r0 A , t j�/j l,�c%ryE� v� a
�U'CO A' Oa�� ,fit S�P1/c 109W J A q44�-- f *l ! jV6 hW -&' ,7 t&AIIX G /" r.✓
JAI1o*1tea w�/�� ,ray A,02f 404P MX•tr�,
As a representative for the responsible party, 1 certify that the information contained in this report is true and accurate to the
best of my knowledge.
Person submitting claim: ;.i ft 4 &Art.MV__
Date: 11� I _�_ _//O i� 141_
Signature: Title: //�i4/�%L�✓A�G�Q/�7�1 �1�!
Telephone Number `�1-;: d/ 33Zv
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).
$0711 ,oU/�ioS Cow4*7�C Al9J� sToPv� tX ?sly ,�v<
/N 9�'� i%IACO%/G 90 1lfG� Cb�/71i4G? we 99W&W7 IAI �4N,o Mec*-'7 QAG✓N �i?F�/yt
Stowe ;Ne Spec F�2r�I @ BS��vM %U 3040m
j/A)7iL 7/�G' CoN?Rf�7v/L j
!tiG k/bQt�
Form CS-SSO Page 13