WQCS00212_Renewal Application_20181121

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2018 Celebrate/Chri/st>inu'with/a/
"Taw iafa/l' Frie.vtd�"
November 21,2018
Ms.Gwyn Ann McCullough, Environmental Specialist RECEI ®(®FNRI®WR
NCDEQ DWR
Water Quality Permitting Section DEC 0 7 2018
PERCS Unit
1617 Mail Service Center Nilstat i g Section
Raleigh, N.C. 27699-1617 p�rmitteng
Re: Renew the Town of Rowland
Wastewater Collection System Permit
Permit WQCS00212
Dear Ms. McCullough,
The Town of Rowland is renewing the wastewater collection system permit.Attached is the
application with associated documents. I apologize for the delay in submitting this information, I am the
new Town Clerk and in the process of reorganizing our management team of two. Our small rural Town
has not kept in touch with more recent technical improvements.We plan on correcting these problems
as soon as possible.
The key element to our Town's growth will be a strong utility system.We applied for and received
an AIA grant for Inventory assessment from the Department of Commerce to evaluate our sewer system
needs.Once the consultants'analyze is complete we plan to implement steps to reduce our I/I issues
and perform some need upgrades to our mechanical systems through the system.
Again, I apologize in the delay in submitting this information. If you have any questions please
contact our Town Hall and talk with either Teressa Williams or myself at 910.422.3333.Thanks again and
enjoy a Happy Thanksgiving.
Sncereely, 221..../#7.:5_____
4:,27.).
David Townsend, Ill, P.E.
Town Clerk
P.O.Box 127,Rowland,NC 28383 ROWLAND FESTIVAL COMMITTEE Phone:[phone]

State of North Carolina
b.
Department of Environmental Quality
} c Division of Water Resources• 15A NCAC 02T.0400—SYSTEM-WIDE WASTERWATER COLLECTION SYSTEMS
Division of Water Resources INSTRUCTIONS FOR FORM CSA 04-16&SUPPORTING DOCUMENTATION
Documents shall be prepared in accordance with 15A NCAC 02T .0100, 15A NCAC 02T .0400, and all relevant
Division Policies. Failure to submit all required items will necessitate additional processing and review time.
For more information, visit the System-wide Collection System Permitting website:
General — When submitting an application to the Pretreatment, Emergency Response, & Collection Systems (PERCS)
Unit,please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to
these instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of
requested additional information.
The Applicant shall submit one original and one copy of the application and supporting documentation.
A. Cover Letter
❑ Submit a cover letter listing all items and attachments included in the permit application package
B. No Application Fee Required
> No application fee is necessary. The permittee will be billed an annual fee upon issuance of the permit
> The appropriate annual fee for systemwide wastewater collection system permits may be found at:
> Annual Non-Discharge Fees
C. System-Wide Wastewater Collection System (FORM: CSA 04-16)Application:
® Submit the completed and appropriately executed System-wide Wastewater Collection System (FORM: CSA 04-
16) application. Any unauthorized content changes to this form shall result in the application package being
returned. If necessary for clarity or due to space restrictions, attachments to the application may be made,as long
as the attachments are numbered to correspond to the section and item to which they refer.
❑ If the Applicant Type in Section I.3 is a Privately-Owned Public Utility, provide the Certificate of Public
Convenience and Necessity (CPCN) from the North Carolina Utilities Commission demonstrating the Applicant
is authorized to hold the utility franchise for the area to be served by the wastewater collection system,or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an
application for a franchise has been received and that the service area is contiguous to an existing franchised area
or that franchise approval is expected.
❑ If the Applicant Type in Section I.3 is a corporation or company, provide documentation if it is registered for
business with the North Carolina Secretary of State.
D. General Information:
> The Authorized signing official listed in Section I.4 should match with that of the Applicant certification page in
accordance with 15A NCAC 02T .0106(b). Per 15A NCAC 02T .0106(c), an alternate person may be designated
as the signing official if a delegation letter is provided from a person who meets the criteria in 15A NCAC 02T
.0106(b).
> NOTE - Public Works Director's are not authorized to sign this permit application according to the rule
unless they are delegated.
INSTRUCTIONS FOR APPLICATION CSA 04-16&SUPPORTING DOCUMENTATION Page 1 of 5

E. Summary of Attachments Required:
❑ Instruction A: Cover Letter
O Instruction C: Application
❑ Instruction C: Ownership Documentation (i.e. CPCN) (If necessary)
❑ Instruction D: Delegation Letter(If necessary for signing official)
❑ Section IV.3 Pump Station List
E l Section IV.4 High Priority Lines List
❑ Section V.4 Annual Budget for Collection System (Updated and Approved)
El Section V.6 Capital Improvement Plan (Updated and Approved)
El Section VI.2 Response Action Plan
❑ Section VI.4 Contingency Plan
❑ Section VI.6 Comprehensive Collection System Map
❑ Section VII Note Any Potential Compliance Issues
THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS,SHOULD BE SENT TO:
NCDEQ-DWR
Water Quality Permitting Section
PERCS UNIT
By U.S.Postal Service: By Courier/Special Delivery:
Attn: PERCS Unit Supervisor 512 N.SALISBURY ST.Suite 925
1617 MAIL SERVICE CENTER RALEIGH,NORTH CAROLINA 27604
RALEIGH,NORTH CAROLINA 27699-1617
TELEPHONE NUMBER: [phone]
INSTRUCTIONS FOR APPLICATION CSA 04-16&SUPPORTING DOCUMENTATION Page 2 of 5

I. APPLICANT INFORMATION:
1. Applicant's name(Municipality,Public Utility,etc):Town of Rowland
2. Facility Information: Name: Rowland Collection System Permit No.:WQCS00212
3. Applicant type: ® Municipal ❑ State ❑ Privately-Owned Public Utility
❑ County ❑ Other:
4. Signature authority's name: Michelle M. Shooter per 15A NCAC 02T.0106(b)
Title: Mayor
5. Applicant's mailing address: P.O.Box 127
City: Rowland State:NC Zip:28383-0127
6. Applicant's contact information:
Phone number: [phone] Fax number:[phone] Email address:[e-mail]
II. CONTACT/CONSULTANT INFORMATION:
1. Contact Name:David Townsend, III,PE
2. Title/Affiliation:Town Clerk
3. Contact's mailing address: P. O.Box 127
4. City:Rowland State:NC Zip:28383-0127
5. Contact's information:
Phone number: [phone] Fax number: [phone] Email address: [e-mail] and
[e-mail]
III. GENERAL REQUIREMENTS:
1. New Permit or Premit Renewal? ❑New ®Renewal
2. County System is located in: Robeson County
3. Owner&Name of Wastewater Treatment Facility(ies)receiving wastewater from this collection system:
Owner(s)&Name(s):Town of Rowland Wastewater Treatment Plant
4. WWTF Permit Number(s): NC0069612
5. What is the wastewater type? 100%Domestic or %Industrial(See 15A NCAC 02T.0103(20))
1_j Is there a Pretreatment Program in effect? ❑ Yes or❑No
6. Wastewater flow: 0.21 MGD(Current average flow of wastewater generated by collection system)
7. Combined permitted flow of all treatment plants: 0.387 MGD
8. Explain how the wastewater flow was determined: ® 15A NCAC 02T.0114 or❑ Representative Data
9. Population served by the collection system: 1038
IV. COLLECTION SYSTEM INFORMATION:
1. Line Lengths for Collection System:
Sewer Line Description Length
Gravity Sewer 15.25 (miles)
Force Main 6.5 (miles)
Vacuum Sewer 0(miles)
Pressure Sewer 0(miles)
APPLICATION CSA 04-16 Page 3 of 5

2. Pump Stations for Collection System:
Pump Station Type Number
Simplex Pump Stations(Serving Single Building) 0
Simplex Pump Stations(Serving Multiple Buildings) 0
Duplex Pump Stations 3
3. Submit a list of all major(i.e.not simplex pump station serving a single family home)pump stations. Include the following
information:
D Pump Station Name
D Physical Location
D Alarm Type(i.e.audible,visual,telemetry, SCADA)
D Pump Reliability(Can convey peak hourly wastewater flow with largest single pump out of service)
D Reliability Source(permanent/portable generator,portable pumps)
D Capacity of Station(Pump Station Capacity in GPM)
4. Submit a list of all high priority lines according per 15A NCAC 02T.0402(2)known to exist in the collection system. Head
the list with"Attachment A for Condition V(4)"and include the system name.
D Use the same line identification regularly used by the applicant
D Indicate type of high priority line(i.e. aerial),material and general location
V. COLLECTION SYSTEM ADMINISTRATION:
1. Provide a brief description of the organizational structure that is responsible for management, operation and maintenance of
the collection system.
2. Indicate the current designated collection system operators for the collection system per 15A NCAC 08G.020I
Main ORC Name: Joe K.McGirt Certification Number: 16048
Back-Up ORC Name: Ronnie Seals Certification Number: 987420
See the"WQCS Contacts and ORC Report"for a current listing of the ORC(s)the Division has on file for WQCS permit
3. Approximate annual budget for collection system only: $202,555.00
4. Submit a copy of your current annual budget.
5. Approximate capital improvement budge for the collection system only: $ 10,000
6. Submit a copy of your current capital improvement plan.
7. Is this collection system currently a satellite system ❑Yes or®No
8. Do any satellite systems discharge to this collection system❑Yes or®No(If yes complete table below)
Satellite System Contact Information(Name,Address,Phone Number)
Complete for Satellite Systems that have a flow or capacity greater than 200,000 GPD(Average daily flow)
9. List any agreements or ordinances currently in place to address flows from satellite systems:
N/A
APPLICATION CSA 04-16 Page 4 of 5

VI. COLLECTION SYSTEM COMPLIANCE:
I. Is a Response Action Plan currently in place® Yes or❑No
2. If Yes,submit a copy of the Response Action Plan or see table 6 below.
3. Is a pump station contingency plan currently in place?® Yes or❑No
4. If Yes,submit a copy of the pump station contingency plan or see table 6 below.
5. Is a comprehensive collection system map currently in place? ®Yes or❑No
6. Submit a submit a copy of the collection system map(CD or hardcopy)or indicate a schedule for completion
7. Thoroughly read and review the System-Wide Collection System Permit Conditions. Typically;complianceschedules
are onlyofferedtorvN1CW}Permit applicanis, Permit renewals. Any compliance dates must be included within
the permit prior to issuance or the permit holder will be found in violation upon inspection.
Current If no,Indicate a Typical
Permit Condition Compliance Compliance
Compliance? Date Schedule
I(4)—Grease ordinance with legal authority to inspect/enforce ®Yes ❑No 12—18 mo.
I(5)— Grease inspection and enforcement program ®Yes ❑No 12—18 mo.
I(6)—Three to five year current Capital Improvement Plan. ® Yes ❑No 12—18 mo.
1(8)—Pump station contingency plan ®Yes ❑No 3 mo.
1(9)—Pump station identification signs. ®Yes ❑No 3 mo.
1(11)—Functional and conspicuous audible and visual alarms. ®Yes ❑No 3—6 mo.
II(5)—Spare pumps for any station where one pump cannot
handle peak flows alone(in a duplex station,the 2"pump is ®Yes ❑No 6—9 mo.
the spare if pump reliability is met).
II(7)—Accessible right-of-ways and easements. ® Yes ❑No 6—12 mo.
II(9)—Response action plan with Items 9(a—h). ® Yes ❑No 3 mo.
III(3)—Comprehensive collection system map ®Yes ❑No 10%per year
For conditions not listed,compliance dates are not typically offered. List any permit conditions that may be difficult for the
applicant to meet(attach clarification if needed):
N/A
VII. APPLICANT'S CERTIFICATION per 15A NCAC 02T.0106(b):
I, Michelle M. Shooter attest that this application for Rowland Collection System
APPLICATION CSA 04-16 Page 5 of 5

(Signature Authority's Name&Title from Item I.4) (Facility name from Item I.1)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts of this
application are not completed and that if all required supporting information and attachments are not included,this application package
will be returned to me as incomplete.
Note: In accordance with NC General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement,
representation, or certification in any application shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed
$10,000 as well as civil penalties up to$25,000 per violation.
Signature: (/ .u- v"Ylr\.- 74--0-61-12- Date: I 1^ at — Is '
APPLICATION CSA 04-16 Page 6 of 5

Section IV.3
TOWN OF
ROWLAND
Pump
Station List

TOWN OF ROWLAND
PUMP STATIONS
Section IV.3
- Soffe Lift Station
US 301 South
Alarm-audible&visual
Restricted area by 6' chain link&locked
Pump can handle 2.5 times a.d.f.alone
Backup pump on hand
Signs are present with information
- Bracey Branch Lift Station
Joyce Lane
Alarm-audible&visual
Restricted area by 6' chain link&locked
Pump can handle 2.5 times a.d.f.alone
Backup pump on hand
Signs on site with information
- Waffle House
US 301 South
Alarm-audible&visual
Restricted area with locks
Pump cannot handle 2.5 times a.d.f.alone
Backup pump on hand
Signs on site with information
- Welcome Center
1-95—3 mile marker northbound
Alarm-audible&visual
Restricted by fence&locks
Pump can handle 2.5 times a.d.f.
Signs on site
This Pump Station is owned and operated by the N.C. Department of Transportation,
The Town accepts the waste and offers assistance upon request

Section IV. 3
TOWN OF
ROWLAND
High Priority
Improvements List

TOWN OF ROWLAND
IDENTIFICATION OF SOME HIGH PRIORITY
SANITARTY SEWER REPAIRS
As indicated in the Body of the application.The Town is utilizing an AIA Grant to
evaluate the weakness in our sanitary sewer system. Once they are located
the Town intends to pursue funding for the needs repairs and equipment
upgrades. However working with our Public Works Department several
locations are known as potential problem areas for inspection. The locations are
as follows
1. Church Street connection with I-95 Welcome Center pump station.
2. Downtown two blocks, old and shallow sewers are located alleyways
3. Bond Street sewer, Main St. southward to Church St.
4. Chapel Street intersection with Canal Street.

Section V.4
TOWN OF
ROWLAND
Annual Budget
for
Collection System

TOWN OF ROWLAND
2018-2019 Budget
Section V.4
Uw,=,' " ;<°f,:k«:'30aV11ater/,S;ewer.Fun°d <'KJ "'`''=Wl; Expenses
Proposed Budget
DEPT(8110)SEWER DEPARTMENT 2018-2019 AMENDMENT
CONTINGENCY $2,500.00 $0.00
SALARIES $55,750.00 $0.00
FICA EXPENSE $4,300.00 $0.00
MEDICAL INSURANCE $17,500.00 $0.00
LIFE/DISABILITY $1,000.00 $0.00
RETIREMENT EXPENSE $3,100.00 $0.00
UNEMPLOYMENT TAX $220.00 $0.00
TELEPHONE & POSTAGE $2,500.00 $0.00
UTILITIES $25,000.00 $0.00
UTILITIES; HEATING $285.00 $0.00
TRAVEL &SCHOOL $250.00 $0.00
M/R BLDGS. &GROUND $1,000.00 $0.00
M/R EQUIPMENT $18,000.00 $0.00
SEWER LINE REPAIR/HYDS $3,000.00 $0.00
MAINTENANCE & REPAIR/L $2,000.00 $0.00
PICKUP & BACKHOE $2,500.00 $0.00
SEWER TESTS $7,000.00 $0.00
GAS,OIL,FLUIDS $3,500.00 $0.00
TIRES,TUBES $500.00 $0.00
SUPPLIES $4,000.00 $0.00
SUPPLIES-CHEMICALS $5,000.00 $0.00
UNIFORM EXPENSE $900.00 $0.00
CONTRACTED SERVICES $27,000.00 $0.00
DUES,SUBS & PERMITS $2,400.00 $0.00
INSURANCE& BONDS $8,000.00 $0.00
MISCELLANEOUS EXPENSE $3,850.00 $0.00
RESERVE/CAPITAL OUTLAY $1,500.00 $0.00
TOTAL DEPT (8110)SEWER DEPARTMENT $202,555.00 $0.00
9of10

Section V.6
TOWN OF
ROWLAND
Capital
Improvements Plan
FISCAL YEARS
2010/2011 to 2015/2016

TOWN OF ROWLAND
UPDATE
CAPITAL IMPROVEMENT PLAN
As indicated in the Body of the application, the Town is utilizing an AIA grant to
identify and evaluate the weakness in our sanitary sewer system. Unfortunately
attached is the latest Capital Improvements Plan presented and adopted by the
Board of Commissioners. Again, this is an area of improvement the new Town
management team will direct the Board forward into better future planning.

CAPITAL IMPROVEMENT PLAN
DEFINITIONS
The Town of Rowland's Capital Improvement Plan (CIP) is a planning and budgeting tool, which
provides information about the Town's Infrastructure and other capital needs for a five-year
time frame. The first year of the CIP is the Capital Improvement Budget and funding for the
improvement identified therein is contained in the proposed Fiscal Year 2012-2013 Budget.
The remaining four years of the CIP lists the capital projects identified for implementation and
its estimated cost. Each year,the list of projects is reviewed for need; cost and priority. New
projects may be added and other projects deleted.
For this plan, Capital Improvements are defined as physical assets, constructed or purchased,
that have a useful life of five years or longer and a cost of$5,000 or more. Projects that meet
this definition of a capital improvement are included in the budget, such as:
a. New and expanded facilities for the community.
b. Rehabilitation or replacement of existing facilities.
c. Equipment for any public facility.
d. The cost of engineering or architectural studies and services relative to an improvement.
e. The acquisition of land or a community facility such as a park, road, sewer line, and etc.
f. Purchase of vehicles or equipment is included in the CIP, when it has an expected life of
three years or more, and a cost of$5,000 or greater.
CAPITAL OUTLAYS
Capital Outlays,which are budgeted within the Town's operating budget, include such things as
furniture, equipment,vehicle, and motorized equipment needed to support the operation of
the Town's programs. Generally, a capital outlay item may be defined as an item valued in
excess of$500 with a life expectancy of less than 10 years.
Capital Outlays includes minor construction projects, landscaping projects, and facility repairs
valued between $500 and $5,000. However,for purposes of our budgeting needs, staff has
combined small projects into a Capital Project when collectively they may relate to an overall
improvement program or project for a facility or system.

CAPITAL PROJECTS
There are two types of capital expenditures. One deals with infrastructure projects and the
other with operating programs. Capital Projects, which are addressed in the CIP and budgeted
within the Town's Adopted Budget, generally include major fixed assets or infrastructure with
long term value, such as buildings, streets, and equipment, and may involve some form of debt
financing.
Capital Project costs include all expenditures related to the planning, design, construction and
equipment necessary to bring a facility on line.
CAPITAL IMPROVEMENT PROGRAMS
The CIP provides information on the current and long-range infrastructure and equipment
requirements of the Town. It provides a mechanism for balancing needs and resources and for
setting priorities and schedules for capital projects. Itis based on needs identified through a
planning process, request and recommendations of Town departments and the concerns of
citizens and elected officials. The CIP included identification of the revenue sources, which will
be utilized to fund capital improvements. For this CIP, projects maybe included even if
offsetting revenues will not be available to fund them. Projects may be funded by current
revenues or by debt financing, depending on the availability of funds,the nature of the project,
and the policies of the Town Board.
The CIP combines all the Town's individual department plans and coordinates them with the
Town's Comprehensive Land Use Plan. The CIP spells out what each department sees, as its
future needs and the means to achieve those goals.
The CIP strives for efficient use of capital improvement funds by identifying CIP projects and
prioritizing them according to their relative importance and urgency of need. Identification
assures needed projects are being funded while prioritization ensures that those projects,
which are more urgently needed, are funded first.

ROWLAND'S COMPREHENSIVE LANE USE
PLAN
New and evolving funding requirement by federal and state agencies are beginning to require
that local governments prepare a comprehensive plan, which will guide public capital
investments, other public fiscal policies, operating policies of the Town's government, and the
future use of land in the Town. The Town of Rowland adopted its first Comprehensive Lane Use
Plan (a project that was funded by the N.C. Rural Development Center) in May of 2003. This
comprehensive plan may be amended up to twice a year, and must be evaluated and updated
every five years.
The information contained within the Comprehensive Land Use Plan provides direction and a
means with which to prioritize needed capital facilities.
CAPITAL IMPROVEMENT BUDGETS
The five-year Capital Improvement Budget lays out planned capital expenditures over a five-
year period. Funds budgeted through the CIP for a specific project remain with that project
until the project is completed, while the operating budget "terminates" at the end of each
fiscal year.
Each year project costs will be reviewed and additional funds may be allocated to a project
which, when combined with monies carried over the prior year, constitute the budget for the
new year.
PROJECTION PRIORIZATION
When departments make their request for capital project funding, priority is given to projects
needed to meet the goals and policies as defined by the Town Board. Prioritizing Town goals is
then necessary in order to allocate the potential revenue sources to projects each year.
Since Enterprise activities, such as Utilities have their own funding sources,they do not
compete with other Town projects for funding. Each area's goals and objectives state certain
levels of service to be maintained and capital project are requested based on that need.

PROJECT COSTING
It has proven difficult to develop accurate scopes, cost estimates and schedules for projects on
which no preliminary engineering or other work has been done. The project costs to be funded
within the CIP should include all cost related to design, acquisition, construction, project
management, equipment, legal expense, mitigation of damages,title costs and other land
related costs, computer lines,telephone lines, etc., when such information is available. Each
year the CIP may be adjusted, as complete project costs become more firmly known.
FINANCING DECISIONS
Financing decisions are made based on established Town policies and available financing
options. The most obvious option is to use cash resources; however, like many small, rural
Towns in North Carolina,the Town of Rowland has limited cash resources available. In order to
meet the goals and objectives of the Town Board and the Comprehensive Lane Use Plan, other
financing options for the CIP must be explored. These options are directly related to project
timing and choice of revenue source. The Town must investigate other options to fund
necessary CIP projects such as grants, user fee, bonds, capital leases and loans, and increased
user fees and property taxes
REVENUE SOURCES
The Capital Improvement Plan and Capital Budget indicate the fund responsible for funding the
specific projects. However, CIPs usually include a variety of revenues that are used both for the
direct funding of projects and as a source for debt service to retire bonds. Since the Town of
Rowland has a limited tax base and fund balance,the Town of Rowland will seek any
available grants or subsidized loans for the completion of significant Capital Improvement
Plan projects to funding the projects with other Town revenue source. This section will
describe each of the major revenue sources other than grants or subsidized loans,with
particular emphasis upon how funding is determined and for what purpose those monies will
be allocated. Enterprise Funds will report their CIP within their respective funds, with offsetting
Revenues and Expenditures. Funding of these projects will be from the operating revenues
generated within the Fund, although several of the revenue sources listed below are also
available.

CAPITAL PROJECT ACCOUNTS
The Capital Project Accounts will be established for the Town's General Fund projects. The
primary resources of revenue for the Capital Improvement Fund are General Fund revenues
and grant sources. Currently the Town does not identify any specific revenues with the General
Fund to support Capital Improvements. The Town needs to develop and adopt a policy defining
revenue sources for the Capital Improvements Plan. Examples of revenue sources, which could
be used, are identified below:
Ad Valorem Taxes
Rowland property owners could pay a portion of their property tax for capital improvements.
This can be accomplished through two methods: (1) Voter referendum,for example, should
the Town decide to build a new library,they could place this on referendum to finance through
General Obligation bonds with Ad Valorem Taxes pledged on the debt; or, (2) the Town could
identify a portion of the approved millage to be dedicated to funding the Capital Improvement
Plan.
Bonds
As a municipal government, Rowland may issue tax-exempt bonds to finance capital
construction. A great variety of revenue sources may be used to repay these bonds. Outlined
below are the several methods of funding various departmental bonded projects.
Ad-Valorem Taxes
These projects would be funded by utilizing a pledge of Ad-Valorem taxes. General Obligation
Bonds requires a voter-approved referendum.
Non Ad-Valorem Taxes .
These projects would be funded utilizing a pledge on non-Ad-Valorem revenues. These
revenues would include State Shared Revenues, permit fees and others.

Lease Purchase
The Town may purchase buildings or equipment utilizing a lease-purchase agreement. This
allows for the project to be undertaken and annual "lease" payments to be made to repay the
costs, This differs from a bond since a lease-purchase is not a long-term obligation; it is
structured so that the continuation of lease payments is subject to annual appropriation. If the
Town does not budget for the lease payment,there is no further obligation on the part of the
Town to continue the arrangement.
ENTERPRISE FUNDS
Revenue Bonds
There are projects within the Enterprise Funds for Water and Sewer, which could be bond
financed by pledging revenue generated from the operation of these facilities. These bonded
projects would stipulate that revenues from the provision of water or sewer services would
provide debt service on these bonds.
CURRENTLY IDENTIFIED
CAPITAL IMPROVEMENT PROJECTS
*(Prioritized according to relative importance and urgency of need, with Number 1 being the
most important and urgently needed).
1. Replacement of decaying existing water lines at various locations throughout the Town of
Rowland
Many of the aging water lines throughout the Town of Rowland are in a state of serious
decay and are continuing to deteriorate at a rapid rate. The breaks and fissures in thee lines
creates a high possibility of the citizens of the Town of Rowland receiving water that has been
polluted by contaminates leached into the water lines.
The decaying water lines through the Town of Rowland must be replaced as expeditiously as
possible.

Estimated Project Cost: Depending on size of total project
Proposed Funding Source: Seeking grant sources
2. Rehabilitation of sewer system at various locations throughout the Town of Rowland
As a direct result of a 2001/2002 investigation (funded by the North Carolina Rural
Development Center)to identify and quantify the magnitude of storm water inflow and
groundwater infiltration to its sewer collection system, it is necessary to rehabilitate
gravity sewers at various locations throughout the Town.
The work performed during the 2001/2002 NC Rural Center funded study included "top-
side" observations of manholes,flow monitoring, review of historical and current water
and sewer records, and observation of a portion of the sewer collection system through
use of a television camera. This work resulted in several findings that were published in a
report prepared at the conclusion of the investigation. Findings discussed in the report
include:
• Inflow of storm water into the town's collection system was found to be minimal.
However, infiltration of ground water into the collection system was determined to
be significant.
Estimated Project Cost: Depending on total size of project
Proposed Funding Source: Seeking grant sources
3. Improvements to Town of Rowland Recreational Facilities
In a continued effort to better serve the needs of the Town's citizens,the Town of
Rowland plans to make substantial improvements to the Town's public recreation
facilities. These improvements will include the installation of new playground
equipment and walking trails.
Estimated Project Cost: Depending on total size of project
Proposed Funding Source: General Fund

Sect on VI 2
TOWN OF
ROWLAND
Spill Response
Action Plan

SectionVl.2
TOWN OF ROWLAND
SPILL RESPONSE ACTION PLAN
A. Town of Rowland Public Works Department
Names and Necessary Phone Numbers
Jessie Watson Cell: 910-827-9272
Steve Richardson Cell: 910-733-3250
Joe McGirt Cell: 910-374-5333
Cedric Baker Cell: 910-405-0424
David Townsend Cell: 336-257-0274
Town of Rowland Admin: 910-422-3333
Sewer: 910-422-3211
B. Response Time:
The Town of Rowland has a response time to emergencies and spills of approximately
30-60 minutes.
C. Town of Rowland Spill Response Action Plan Equipment& Spare Parts List
1. Sreco Flexible Flusher
2. 3-inch Sludge Pump w/hose .
3. 3-inch Water Pump w/hose
4. Tripod and Harness
5. 3kw Generator for Lighting
6. 215 JCB Backhoe w/3-inch Sump Pump
7. Spare Pumps for Lift Stations
8. Misc.Valves and Fittings
D. The Town of Rowland has the following agencies available for cleaning of lift stations and
sewer lines.
, Town of Rowland Phone: [phone]
910-422-3211
Brian's Septic Tank Service Phone: [phone]
Porter Environmental Phone: [phone]
Cell: 910-827-9745

SectionVl.2
E. Construction Crews,Contractors and/or Engineers
Charles Underwood Company 800-729-2463
919-775-2463
Thompson's Electrical 910-422-3794
910-704-0984(Cell)
Sanford Electrical Contractors Inc 919-774-4533
Frank Horne Construction 910-649-7201
Ricky Locklear Construction 910-628-7534
910-827-0322 (Cell)
F. The Town of Rowland has funds allocated in the following fund(s)for emergencies and spills.
The Sewer Fund
G. The Town of Rowland has the following materials for site sanitation and clean up:
1. Lime
2. Disinfecting Products
3. Waste Bags
4. Hand Tools (shovels, racks)
5. PPE—Personal Protection Equipment(gloves,eye protection)
H. The Town of Rowland will make a Post—SSO assessment following any spill(s)to make sure all
contaminants and debris are cleaned up to make the site safe and clear for the Public's health.

Sect on VI 4
TOWN OF
ROWLAND
Contingency
Emergency
Response Plan

Section VI.4
Town of Rowland
Public Works Department
Emergency Response Plan
Emergency Response Plan
1) All personnel shall monitor weather conditions frequently. Television and radio,
such as the weather station or local news outlets, should be used to monitor
weather conditions.
2) In the event of an approaching hurricane, all door and windows shall be taped
and any lose materials around critical Town buildings (Town Hall, WWTP, well
houses) will be secured. Batteries and flashlights will be collected and placed in
a convenient space in the event they are needed. Town vehicles and all extra
gasoline storage cans will be filled up with fuel. The diesel tank for the
emergency generator will be topped off in the event a power failure requires the
generator to be placed into service.
3) All personnel will be placed on emergency stand by status by the Mayor. The
Town Hall will be manned by the Public Works Director and any other available
personnel. If needed, personnel will be stationed at well houses or at the
WWTP. Personnel will be dispatched to these areas under the direction of the
Public Works Director. The water and sewer systems will be operated under
normal conditions and water tanks should be kept as full as possible. The facility
will go to emergency power in the event power is lost. The transfer to emergency
power must be completed manually.
4) If the Town Hall, WWTP, or well houses become unsafe for personnel to occupy,
employees are to evacuate to the Rowland school.
5) If needed, the Public Works Director will shut down the groundwater supply wells.
The Director will bring wells back on-line as soon as conditions allows.
6) After a hurricane strike, all available personnel shall make themselves available
to clean up debris and restore the system to normal operation.
7) The Rowland Director of Public Works is ultimately responsible for implementing
these procedures and accounting for all personnel during and after the hurricane.

Section VI.4
Fire Emergency Response Plan
1) An employee at the wells or WWTP who suspects a fire is required to investigate.
If a fire is discovered, the employee should proceed with caution.
2) The person who discovers a fire is responsible for reporting the fire to the Town
Hall and the Rowland Rural Fire Department. The person shall provide the Fire
Department with the location and nature of the fire.
3) If possible, the person who identifies the fire should take measures to extinguish
the fire. However, no action should be taken to put the safety and well being of
the employee at risk.
4) Rescue and medical duties can only be completed by trained personnel
(EMTS,Hazmat, etc...).
5) Public Works employees shall follow directions of the responding Fire
Department and make themselves available to assist as directed.
Fire Prevention
1. Smoke detectors shall be checked every six months to ensure proper operation.
Smoke detectors are located in the well houses, at the wastewater treatment
plant, and in the Town Hall. The Public Works Director shall retain responsibility
for checking the smoke detectors.
2. Fire extinguishers shall be checked quarterly to ensure proper operation. Fire
extinguishers are located at the well houses, at the wastewater treatment plant,
in the Town Hall, and in all Town vehicles.
3. Possible fire hazards encountered by the Public Works staff include: gasoline,
acetylene, oils, paint, and aerosol cans. Such materials are located at the
WWTP.
4. Proper housekeeping procedures must be followed by all town employees. Each
employee is responsible for storing all chemicals or reagents in their proper
places. All acids and flammable chemicals are used or made up under the fume
hood to eliminate possible hazards. All areas should be kept clean to reduce
hazards.
5. The Public Works Director is responsible for maintenance of equipment related to
fire prevention and the control of any type of fire hazard that might arise.

Section VI 6
TOWN OF
ROWLAND
Comprehensive
Collection
System Map

TOWN OF ROWLAND
OVERALL SEWER MAP
As indicated in the Body of the application.The Town is utilizing an AIA grant to
identify and evaluate the weakness in our sanitary sewer system. Once the
weaknesses are noted, the Town intends to pursue funding for the needs
repairs and equipment upgrades.The attached photo indicates what we have
progressed to the point of a very good and accurate sanitary sewer system map.
A true hard copy of the map will be forthcoming once our Consultants provide
them to us after Thanksgiving.

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Sect on VII
TOWN OF
ROWLAND
Potential
Compliance
Issues

TOWN OF ROWLAND
POTENTIAL COMPLIANCE ISSUES
Attached are the documents related to a serious of three overflows that
occurred during Hurricane Florence on September 15, 2018. During the storm
the Town received over 16 inches of rain and unfortunately overloaded our
system. With additional funding the Town anticipates improving these I/I
problems.

PRESS RELEASE
Notice of Discharge of Untreated Sewage
General Statute 143-215.1C requires that the owner or operator of any
wastewater collection or treatment works to issue a press release when an
untreated wastewater discharge of 1,000 gallons or more reaches surface waters.
The Town of Rowland had a discharge of untreated sewage between September
15, 2018 through September 19, 2018 for approximately 68 hours of an estimated
20,400 gallons at manhole#8 located on Canal Street between Church Street and
Jackson Street, manhole #2 located on Leach Street prior to reaching the Waste
Water Treatment Plant of 46,800 gallons lasting approximately 95 hours, and
manhole #6 located at Canal and McCormick of 4,080 gallons lasting
approximately 68 hours. The untreated wastewater entered into the Town
drainage canal in the Lumber River Basin.
The Division of Water Resources was notified of the event on September 15, 2018
and is reviewing the matter. For more information contact the Town of Rowland
at [phone].
9/28/2018

PUBLIC NOTICE
NOTICE OF DISCHARGED OF UNTREATED SEWAGE
The Town of Rowland had a discharge of untreated wastewater from our
wastewater collection system manhole#8 located on Canal Street between
•
Church Street and Jackson Street of approximately 20,400 gallons lasting
approximately 68 hours, manhole # 2 located on Leach Street prior to reaching
Waste Water Treatment Plant of 46,800 gallons lasting approximately 95 hours,
and manhole # 6 located on Canal & McCormick Street of 4,080 gallons lasting
approximately 68 hours. The discharge occurred on September 15, 2018
through September 19, 2018. This untreated wastewater entered into Town
drainage canal in the Lumber River Basin. This notice was required by North
Carolina General Statutes Article 21, Chapter 143.215C. For more information
contact Joe McGirt, ORC at [phone].
9/28/2018

rf •
State of North Carolina
Department of Environment and Natural Resources
1,3 A ;'� '{t. Division of Water Resources
2:7X11 n
Collection System Sanitary Sewer Overflow Reporting Form
Division of Water Resources Form CS-SSO
PART I:
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: ,1/GDD4' 6/2 (WQCS#if active,otherwise use WQCSD#)
Facility: 7 ',i oocieas✓/!e!G/ Incident#: Q26/170/475/ Owner: /e1,-"/1meow/o
Region: iczy-e•-77`1.-"://e City: Xo�4,s,1 County: /Qv��Soil
Source of SSO(check applicable): J.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.): 5.f•
Manhole#:
Latitude(degrees/minute/second): /vat/°3.2 a 1(9 Longitude(degrees/minute/second): t40790/7, eggs
Incident Started Dt: 9-4/, Time: //iO/,f,! Incident End Dt: 9—/9-4, Time: 7Ce:),52',71
(mm-dd-yyyy) (hh:mm)AM/PM (mm-dd-yyyy) (hh:mm)AM/PM
Estimated volume of the SSO: L/j SdD gallons Estimated Duration(round to nearest hour): 68 hour(s)
Describe how the volume was determined: /41, 9e r/
Weather conditions during the SSO event: /71G;/-r9
Did the SSO reach surface waters? Domes ❑ No ❑ Unknown
Volume reaching surface waters: gallons -Surface water name: 7`0A.4
Did the SSO result in a fish kill? ❑Yes /FIN° ❑Unknown Seo C".z.e<
If Yes,what is the estimated number of fish killed?
SPECIFIC cause(s)of the SSO:
"Sjsevere Natural Conditions ❑ Grease ['Roots ❑Inflow&Infiltration
❑Pump Station Equipment Failure ❑Power Outage ❑Vandalism ❑Debris in line ['Pipe Failure(Break)
❑Other(Please explain in Part II) ,may/
24-hour verbal notification(name of person contacted): /i1.0r/'4 i/'a iz/y
,DWR ❑Emergency Management Date(mm-dd-yyy):e,/G Yf Time:(hh:mm AM/PM): //, 'f#M
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 II IS COMPLETED,A SIGNATURE IS REQUIRED SEE PAGE 13
•
Form CS-SSO Page 1

.r
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"
"iin/detail:
How much advance warning did you have and what actions were taken in preparation for the event?
Comments: Z--c%',VGV, G�frid�! !—�v�� e !/ � ri �5 G✓o%�ij s
Form CS-SSO Page 3

System Visitation •
ORC es ❑ No
Backup'/ ❑Yes El No
Name: -� /0/G�il1�
Certification Number: e,3/
Date visited: iev-/� ay, .
Time visited: f�vz/7 02..Ars
How was the SSO remediated(i./e.Stopped and cleaned up)?
Xe,/%7 z5.7.4y V
As a representative for the responsible party,I certify that the information contained in this report is true and accurate to the
best of my knowledge.
Person submitting claim: SXR ClT//"/ Date: 9 024P'/�
Signature: ,/6e ---,-1-1--"45;:2 Title: , i e
Telephone Number:
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

4 - 1
•
--
k•-•
I ..,
,

State of North Carolina
`' Department of Environment and Natural Resources
_ SAF
Division of Water Resources
Collection System Sanitary Sewer Overflow Reporting Form
Division of Water Resources 1 Form CS-SSO
PART I:
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:/I/000656/Z (WQCS#if active,otherwise use WQCSD#)
Facility: 7,w�aF/eos.'%, ' Incident#: ,20/$D//�!f Owner: Tow'' o,GC-Geas.,4.0.
Region: G y ,//e, City: le 6-1---,44,, County: o/rf6,,
Source of SSO(check applicable): Enitary Sewer ❑ Pump Station/Lift Station
SPECIFIC location of the SSO(be consistent in description from past reports or documentation-i.e.Pump
Station 6,Manhole at Westall&Bragg Street,etc.): Ca/10/S7L .eG�u{e-4 eAe/re-44- Tee c-- soy9
Manhole#: #ec?
Latitude(degrees/minute/second): 4/3 V".3.2,2/8' Longitude(degrees/minute/second): 14,079'77,$S-2'
Incident Started Dt: 9-/4"'/S Time: //.b�,# ? Incident End Dt: 9–/?/a Time: D 7;0.0 ,97
(mm-dd-yyyy) (hh:mm)AM/PM (mm-dd-yyyy) (hh:mm)AM/PM
Estimated volume of the SSO: .20 gallons Estimated Duration(round to nearest hour): 68 hour(s)
Describe how the volume was determined: -es 60,..7,,,,,17 A''i ' /60'S,m iQo,As 1ST
Weather conditions during the SSO event: /7!//'/^/—A,7 c /4/.%"/'-e./.7 �__,
Did the SSO reach surface waters? Eriles ❑ No ❑ Unknown
Volume reaching surface waters: Ili–L__ gallons -Surface water name: ;/vim Griil.4--/
Did the SSO result in a fish kill? ❑Yes )No ❑ Unknown sl70f�-..�/e/"- G,<--
If Yes,what is the estimated number of fish killed?
SPECIFIC cause(s)of the SSO:
Severe Natural Conditions ❑ Grease ❑Roots ❑Inflow&Infiltration
❑Pump Station Equipment Failure ❑Power Outage ['Vandalism ❑Debris in line ['Pipe Failure(Break)
❑Other(Please explain in Part II) ✓y
24-hour verbal notification(name of person contacted): /i/ -,. C . 2/i .,7-7L/4,-
/�6', ,'-7L/-
I WR ❑Emergency Management Date(mm-dd-yyy): 7//i 7"? Time:(hh:mm AM/PM): //Off
• 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 II 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:
h/Z0'7%641/7 , 7. /1- - —
How much advance warning did you have and what actions were taken in preparation for the event?
Comments: 2.4:9A.-er- /'�v e.if /' GAS a a.4
Form CS-SSO Page 3

System Visitation
ORC a< ❑ No
Backup CI Yes ❑ No
Name: SX/PS •/i'.,4"
Certification Number. ga3/
Date visited: �L..cr��
Time visited: ftv-e-iy o2. 4,I 5
How was the SSO remediated/ (i./e.Stopped and cleaned up)?
/67,7 5.74,. /
As a representative for the responsible party.I certify that the information contained in this report is true and accurate to the
best of my knowledge.
/"7 17 � r _
Person submitting claim: —' � E // ��Date: 9 .
Signature: `��C /—LP Title: ",E __-,
Telephone Number:
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

,
State of North Carolina
fill"'" 1 Department of Environment and Natural Resources
.tsr Division of Water Resources
Collection System Sanitary Sewer Overflow Reporting Form
Division of Water Resources Form CS-SSO -
PART I:
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: /1/l D‘,�jC66-2.. (WQCS#if active,otherwise use WQCSD#)
Facility: 72 .A �Fioti./tin' Incident#: go/R.11 a 9,21 Owner: 7;71",-,1 opc ds.,/,s.1'
Region: afar e:,7 e,-, 0 City: leo G✓4 County: "e".10-<4,,..7
Source of SSO(check applicable): I-nitary 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.): /244,,,Zok/G LGi uA s/ Tia/aI _ et a— .r,•e,�.0.4
Manhole#: ,t'2�
Latitude(degrees/minute/second): 4/37°sot //O' Longitude(degrees/minute/second): '!.t/D7!°/2' f7
Incident Started Dt: G1•—/5—/,Q' Time: /6/%4? Incident End Dt: 9-19—/S" Time: O /lO /3717
(mm-dd-yyyy) (hh:mm)CAM/PM (mm-dd-yyyy) (hh:mm)AM/PM
Estimated volume of the SSO: di"pe gallons EstimatedteDuration(round to nearest 1 r):q,chour(s)
Describe how the volume was determined: .t2,S%/4-i•c�.co./ l� /O/✓ /60 •iso ,ks 71.0,4
Weather conditions during the SSO event A7'v//'/G.r• G #0474:=/'G/!G G�
Did the SSO reach surface waters? J Yes ❑ No ❑ Unknown / ll
Volume reaching surface waters: ��j ROd gallons Surface water name: ,...0 Ae,C/
Did the SSO result in a fish kill? ❑Yes ❑ No ❑Unknown
If Yes,what is the estimated number of fish killed?
SPECIFIC cause(s)of the SSO:
Jevere Natural Conditions ❑ Grease ['Roots ['Inflow&Infiltration
['Pump Station Equipment Failure ❑Power Outage ['Vandalism ❑Debris in line ❑Pipe Failure(Break)
['Other(Please explain in Part II)
24-hour verbal notification(name of person contacted): ,,,./ 40/G�, /
[[ (hh:mm❑Emergency Management Date(mm-dd-yyy): Del-Y '-/$'Time:" AM/PM): /p.4:07
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 I1 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:
/7/ ././'ie /� /oma-., G
How much advance warning did you have and what actions were taken in preparation for the event?
Comments: LDA/ -c-i- L-e veJ i lief es,
Form CS-SSO Page 3

System Visitation
ORC LtJs ❑ No
Backup 0 Yes 0 No
Name: S /< /r £- --j 71—
Certification
`Certification Number: 64o
Date visited: V{P y%Gt 7
Time visited: ry 0Z h4Ys
How was the SSO remediated(i./e.Stopped and cleaned up)?
'&4/7 5 67,,��
As a representative for the responsible party,I certify that the information contained in this report is true and accurate to the
best of my knowledge. /�
Person submitting claim: 5/1� //�'( (ii/ Date: `�/ --2,/,"
Signature: Title: ..���
Telephone Number:
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