WQ0004910_Sanitary Sewer Overflow_20200213

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DW Rt S ate of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Collection System Sanitary Sewer Overflow Reporting Form
Division of Water Resources
Form CS-SSO
PART is
This form shall be submitted to the appropriate DWR Regional Office withinthe ines a s of the first knowledge of the
sanitary sewer overflow(SSO ,
QOO) /C?
Permit Number: (WQCS#i;active, otherwise use WQCSD#)
Facility: 14/10 kid i;J1? Ie U.4 re,
Incident /— O 1 ��,,�
�/#: / Owner; Iv '1 JT' � 'i / A)C
Region: kale i:9A City: Wood fa/ri County:` ,�,/ Aiir�"ha/X,toe
Source of SSO(check applicable): 2 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 Westail&Bragg Street,etc.): / ..�
Manhole#; Lg C inler5ectivr1 JP Lind" 't' P�cr t✓!"e Sr
Latitude(degrees/minute/second): Longitude(degrees/minute/second): _ nM
Incident Started Dt:OQ a'I(M Lo
Time: 7 b3O p0e — 1'd 'ZC' 9' '�4 r,i
Incident End Dt; Time:
(mm-dd-yyyy) (hh:mm)AM/PM (mm-dd-yyyy) (hh:mm)AM/PM
Estimated volume of the SSO: :WV gallons_ Estimated Duration (round to nearest hour):Ahour(s)
Describe how the volume was determined: 5 i i P1ci, RECEIVED
Weather conditions during the SSO event: S it r ny'
Did the SSO reach surface waters? FEB 13 2020
I� res ❑ No ❑ Unknown
Volume reaching surface waters: ZOO gallons Surface water name: d�ee j �{!IaI/1 DDEQIDWRINPDES
Did the SSO result in a fish kill? [] Yes Q o ❑Unknown
If Yes,what is the estimated number of fish killed?
SPECIFIC cause(s)of the SSO:
Severe Natural Conditions El Grease ❑Roots nflow& Infiltration
['Pump Station Equipment Failure 0 Power Outage ['Vandalism El Debris in line ❑Pipe Failure(Break)
❑Other(Please explain in Part iI) /� G - Pc�
24-hour verbal notification(name of person contacted): CaII cc� �� /,� 4-2�/'Z Le fs�vy p'J e�1[ WR ❑Emergency Management Date(mm-dd yyy).0-2 ,� Time: (hh:mm AM/PM): i1 S+�h7
Per G.S. 143-215.1 C(b),the owner or operator of any wastewater collection system shall: f
In the event of a discharge of 1,000 gallons or more of untreated wastewater to the surface waters
tesofthe
a State, issue
press release to all print and electronic news media that provide general coverage in
dischargemg the county where the
rg occurred settingout the e details of the discharge. The press release shall be issued within 24 hourse
the owner or operator has determined that the discharge has reached surface water State. aft_r
s of the
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 NO]fART it IS COMPLETED,&SIGNATURE IS REQUIRED SEEP GE 13
Form CS-SSP Psgc i

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Severe Natural onditions (hUPrlcane, tornado, etc.)
Describe the"severe natural condition"in detaii:
how much advance warning did you have and what actions were taken in preparation for the event?
Comments:
(evict h
j i� nUrid ,,`fist h vy ``rids a - i ar an d f v5S ;�p PsW
pr�per-��' `o J .We- c i��C'e 7I,1g gem s-af01-) T.) be-501- .,,
/ /5
1^ � /_. �/�/G d1Cl n d <Jcie ,°c iel`, We %'e± v �PJ �f o 11 i
c
L s 5 pi-eal 0h7c,hl May df / fer-5 ectiPub o ' iticiet
Pic-4 . ee 5 T-fr.eer5
Form CS-SSO
P8gc 3

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Inflow and Infiltration
Are you under an SOC (Special Order by Consent)or do you have a schedule El Yes E]N
in any permit that addresses I/I? ❑NA El NE
Explain if Yes:
What corrective actions have been taken to reduce or eliminate I& I related overflows this spill location
within the last year?
�.i'n i- j'Ji `�' -er-�"i Floc n e7i'p�aG ;ii Nl•i -
Has there been any flow studies to determine I/1 problems in the
collection system at the S$O location? des ❑ No DNA ❑ NE
If Yes.when was the study completed and what actions did it recommend?
Has the line been smoke tested or videoed within the past year? I
Mo nail � ❑ Yes rye DNA El NE
.
If Yes,when and what actions are necessary and he' to us of such actions:
Are there I/I related projects in your Capital Improvement Plan?
Ue- h v9 �'��_/r ( 'S'es El Na DNA Li NE
If Yes,explain: , aryl e� �!?/'
c, o86- T </re 1-A e pet e 06'inS
Have there been any grant or loan applications for in reduction projects? 1-_ �s El No
DNA ❑ NE
.
If Yes,explain:33 e - A-hciire
Do you suspect any major sources of inflow or cross connections ,�
with storm sewers? El Yes Ud"No ❑NA El N�
If Yes,explain;
Have all lines contacting surface waters in the SSO location and upstream
been inspected recently? ❑ Yes ❑ No [ q El NE
If Yes,explain:
What other corrective actions are planned to prevent future I/I related SSOs at this location?
5 —W
Comments: CA v 113'r4 ck-
Form CS-SSO
Pagc6

System Visitation
isitation
ORC Laqi fe ' Yes
Backup Yes
Name. G�
Certification Number: ;2 O '6 14 5 i-7 1/Q
6o
Date visited: 1'e ,2 A2-40
Time visited: 3 eso M1
How was the SSO remediated (i./e. Stopped and cleaned up)?
There ilia a 5 No 11;`J It 0 d ire t-lY/0 iuryy, v r eg Wa /i' i✓0 e d
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: m,k j 4if; 4 is Date: Q 1 - 0.7 26,- £
r �
Signature: /�1! ` Title: R
Telephone Number: "25;73 ? °/ 1
de_ a7f? 53‘ ---_ A:A3
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