NC0021849_SSO Report_20191115 (3)

State of North Carolina
Department of Environment and Natural Resources
DWR 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 Num ber: WQCS00209/NC0021894 (WQCS# if active, otherwise use WQCSD#)
Facility: Town of Hertford WWTP lncident#: 201901768 Owner: Town of Hertford
Region: Washington City: Hertford County. Perquiinans
Source of SSO (check applicable): t9 Sanitary Sewer ❑ Pump Station / Lift Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation -i.e. Pum p
Station 6, Manhole at Westall & Bragg Street, etc.): WWTP influent
Manhole#:
Latitude(degrees/minute/second): Longitude(degrees/minute/second):
lncidentStarted Dt: 11/912019 Time: UNK Incident End Dt: 11110/2019 Time:08:00AM
(mm-dd-yyyy) (hh:mm)AMIPM (mm-dd-yyyy) (hh:mm)AM/PM
Estimatedvol umeofthe SSO: 70000gallons Estimated Duration (round to nearesthour): 16 hour(s)
Describe how the volume was determined: Influent flow
Weather conditions during the SSO event: Clear and cold
Did the SSO reach surface waters? ❑ Yes ❑ No 13 Unknown
Volume reaching surface waters: UNK gallons Surface water name: Unnamed tnbutary and swarnptoPerquimans
River
Did the SSO result in a fish kill? ❑ Yes 0 No ❑ Unknown
If Yes, what is the estimated number offish 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)
24-hourverbal notification (nam a of person contacted): Randy Sipe
®DWR ❑ Emergency Management Date (mm-dd-yyy): 11/13/19 Time:(hh:mmAMIPM).09:00AM
Per G.S. 143-215.1 C(b), the owner or operatorof any wastewater collection system shall:
In the event of a discharge of 1,000 gallons or more of untreated wastewaterto the surfacewaters of the State, issu e
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 owneror operator has determined thatthe 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 thatis significantly affected by the discharge. The
Regional Office shall determine which counties are signi€icentlyaffected bythe 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 I

State of North Carolina
Department of Environment and Natural Resources
DWR Division of Water Resources
Collection System Sanitary Sever Overflow Reporting Form
Division of Water Resources Min CS-SSO
Form CS-SSO Page 2

In order to submit claim forjustification 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 enforcementaction is appropriate.
FART Ih
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 3

Severe Natural Conditions hurricane tornado etc.
Describe the "severe natural condition" in detail;
How much advance warning did you have and what actions were taken in preparation forthe event"?
Comments:
Form CS-SSO Page 4

Grease Documentation such as cleaning, inspection, enforcement actionspast overflow reports, educational
material and distribution date, etc. should he available upon request.)
When was the last time this specific line (or wet well)was cleaned?
Do you have an enforceable grease ordinance that requires new or retrofit of
grease trapsfinterceptors? ❑ Yes ❑ No ❑ NA ❑ NE
Have there been recent inspection and/or enforcementactionstaken on near-
by restaurants or other nonresidential grease contributors? ❑ Yes ❑ No El NA ❑ NE
Explain:
Have there been other SSOs or blockages in this areas that were also caused
by grease ❑ Yes ❑ No El NA ❑ NE
When?
If yes, describethem:
Have cleaning and inspections ever been done at this location? ❑ Yes ❑ No ❑NA ❑ NE
Explain.
Have educational material aboutgrease been distributed in the past? ❑ Yes ❑ No El NA Cl NE
When:
andto whom:
Explain:
If the SSO occurred at a pump station, when was the wet well and pumps lastchecked
forgrease accumulation:
Were the floats clean? Cl Yes ❑ No ❑NA ❑ NE
Comments:
Form CS-SSO Page 5

Roots
Do you have an active root control program on the line area in question?
Describe:
Have cleaning and inspections everbeen increased at this location because
of roots?
❑ Yes ❑ No ❑NA ❑ NE
❑ Yes ❑ No El NA ❑ NE
Explain:
What corrective actions have been accomplished atthe SSO location (and
surrounding system if associated with the SSO)?
What corrective actions are planned atthe SSO location to reduce root intrusion?
Has the line been smoke tested or videoed within the past year? ❑ Yes ❑ No ❑NA ❑ NE
If Yes, when?
Comments:
Form CS-S S O Page 6

Inflow and Infiltration
Are you under an SOC (Special Order by Consent)or do you have a schedule
❑ Yes CR No ❑ NA
❑ NE
in any perm itthat addresses Ill?
Explain if Yes:
What corrective actions have been taken to reduce or eliminate I & I related overflows this spill location
within the last year?
Has there been any flow studies to determ ine IA problems in the
❑ Yes ❑ No ❑ NA
❑ NE
collection system at the SSO location?
If Yes, when was the study completed and whatactions did it recom mend?
Has the line been smoke tested or videoed within the past year?
❑ Yes ❑ No El NA
❑ NE
If Yes, when and whatactions are necessary and the status of such a ctions:
Are there IA related projectsin your Capital Improvement Plan?
❑ Yes ❑ No ❑NA
❑ NE
If Yes, explain:
Have there been any grantor loan applications for III reduction projects?
❑ Yes ❑ No El NA
❑ NE
If Yes, explain:
❑oyou suspect any majorsourcesofinflow orcross connections
❑ Yes ❑ No El NA
❑ NE
with storm sewers?
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream
❑ Yes ❑ No ❑ NA
❑ NE
been inspected recently?
If Yes, explain:
What other corrective actions are planned to preventfuture VI related SSOs at this location?
Comments:
Form CS-SSO Page 7

Pump Station E ui ment Failure Documentation of testina records. etc should be provided upon request
What kind of notification/alarm systems are present?
Auto-dialer/telemetry (one-way communication) ❑ Yes
Audible ❑ Yes
Visual ❑ Yes
SCADA(two-way communication) Yes
Emergency ContactSignage ❑ Yes
Other ❑ Yes
If Yes, explain:
Describe the equipmentthatfailed: Influentbarscreen
What kind of situations triggeran alarm condition atthis station (i.e. pum p failure, powerfailure, high water, etc.)?
Were notification/alarm systems operable? ❑ Yes ® No ❑ NA ❑ NE
In no, explain: SCADA system down
If a pump failed, when wasthe last maintenance and/or inspection performed?
What specifically was checked/maintained?
If a valve failed, when was it last exercised?
Were all pumpssetto alternate?
❑ Yes ❑ No El NA ❑ NE
Did any pump show above normal run times priorto and during the SSO event? ❑ Yes ❑ No ❑ NA ❑ NE
Were adequate spare parts an hand to fix the equipment
❑ Yes
❑ No
❑ NA
❑ N E
Was a spare or portable pump immediately available?
❑ Yes
❑ No
❑ NA
❑ NE
If a float problem, when were the floats last tested? How?
If an auto -dialer orSCADA, when was the system last tested? How? UNK. SCADA Out of commision since early this
year
Comments:
Form CS-SSO Page 8

Power outa a Documentation of testina, records tec., should be provided of altemative power source urion
Eggluest.
What is your alternate poweror pumping source? Generator
Did it function properly? ® Yes ❑ No ❑ NA ❑ NE
Describe?
When was the alternate power or pumping source lasttested under load?
If caused by a weatherevent, how much advance warning did you have and what actionswere taken to prepare forthe
event?
Comments:
Form CS-SSO Page 9

Vandalism
Provide police reportnumber:
Was the site secured?
If Yes. how?
Have there been previous problemswith vandalism atthe SSO location?
If Yes, explain:
What security measures have been put in place to preventsimilar
occurrences in the future?
Comments:
❑ Yes ❑ No
❑ Yes ❑No
❑ NA
❑ NA
❑ NE
❑ NE
Form CS-SSO Page 10

Debris in line Rocks sticks rags and other items not allowed in the collections stem etc.
What type of debris has been found in the line?
Suspected cause or source of debris:
Are manholes in the area secure and intact? ❑ Yes ❑ No ❑NA ❑ NE
When was the area last checked/cleaned?
Have cleaning and inspections ever been increased at this location ❑ Yes ❑ No ❑ NA ❑ NE
dueto previous problems with debris?
Explain:
Are appropriate educational materials being developed and distributed ❑ Yes ❑ No ❑NA ❑ NE
to prevent future sim ilar occurrences?
Comments:
FormCS-SSO Page 11

Other Pictures and police report, as applicable, must be available upon request.)
Describe:
Were adequate equipment and resources available tofixthe problem?
If Yes, explain: Equipment and manpoweravailableto fix oncediscovered
If the problem could notbe immediately repaired, whatactions
were taken to lessen the impactof the SSO?
Comments:
® Yes ❑ No ❑ NA
❑ Yes ❑ No ❑ NA
❑ NE
❑ NE
Form CS-SSO Page 12

Pipe Failure (Break)
Pipe size (inches)
What is the pipe material
What is the approximate age of the lineipipe (years old)
Is this a gravity line?
❑ Yes
❑ No
❑NA
❑ NE
Is this a force main line?
❑ Yes
❑ No
❑ NA
❑ NE
Is the line a "High Priority" line?
❑ Yes
❑ No
❑ NA
❑ NE
Last inspection date and findings
If a force main then,
Was the break on the force main vertical?
❑ Yes
❑ No
DNA
❑ NE
Was the break on the force main horizontal?
❑ Yes
❑ No
❑ NA
❑ NE
Was the leak at the jointdue to gasket failure?
❑ Yes
❑ No
❑ NA
❑ NE
Was the leak at the jointdue to split bell?
❑ Yes
❑ No
❑ NA
❑ NE
When was the last inspection or test of the nearest air -release valve to determine if operable?
When was the last maintenance of the air release performed?
If gravity sewerthen,
Does the I inereceive flow from a force main im mad iately 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 last inspected or videoed?
If line collapsed, what is the condition of the line up and down stream of the failure?
Whattype of repairwasmade?
If temporary, when is the permanentrepair planned?
Have there been other failures of this line in the past f ive years? ❑ Yes ❑ No ❑NA ❑ NE
If so, then describe
Form CS-SSO Page 13

System Visitation
ORC ❑ Yes
Backup ® Yes
Name: Harold Sanchez
Certification Number:
Date visited: 11/10/2019
Time visited: 0830
How was the SSO remediated (i_fe. Stopped and cleaned up)?
Equipment removed and bypassed
Asa representative for the responsible party, I certifytbat the information contained in this report is true and accurate to the
best of my knowledge.
Person submitting Date: 1 j r6
Signature= ( Title:
Telephone Num ber:
Any additional information desired to be submitted should be sent to the appropriate Division Regional Offi ce within five
business days of first knowledge of the SSO with reference to the incident num ber (the incident number is only generated
when electronicentry of this form is completed, if used)"
FormCS-SSO Page 14