NC0020401_Report_20200207

qG Form WWTP-BYPASS/UPSET
E Treatment Plant (VW TP) Bypass/Upset Reporting Form 5 Day Report
..�► PART I
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This form shall be submitted to the appropriate DWQ Regional Office within five days of the first knowledge of the unanticipated
bypass or upset.
Permit Number: ucbv d0Lb( (Always use treatment plant permit number)
Facility: .I,ORTM GA5T- wlarP Incident#
Owner: Czrt( DF I+T-C!�=Qu Region: moy"5UTCLE
City: HTCKOL11 NC County: CAThW Sok
SPECIFIC location of the treatment units bypassed or where the upset occurred in the facility:
Was the WWTP compliant with permit requirements? ❑ Yes ❑ NoL1ef Unknown
Was samples be taken d�^utring bypass?: EYes ❑ No UnknowrD
Incident Started Dt: d~~(0 �20W Time: to ! 3 D Incident End Dt: '2 �rl2OZ0 Time: C,3 D AAA
(mm-dd-yyyy) hh:mm AM/PM (mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the Bypass/Upset: ,
gallons
Describe how the volume was determined:i)lJ2TG(1-Et7
Weather conditions during bypass/upset evept: �' 3 ) n Ages c> fCt i n r n 2.4 V
vela Did Bypass/Upset reach surface waters? U Yes ❑ No ❑ Unknown Volume reached surface waters (gallons): SQ i 400
Surface water name: IF7& L I cr { f—
-ij
Did the bypass/upset result in a fish kill? ❑Yes No ❑Unknown If Yes, estimated number of fish killed?
SPECIFIC cause(s) of the Bypass/Upset: /
-tFFE C 'I �F h o 1% i cko ry (J e cl anew 0. S+c4,° o f b rn lee, ev) c y/
c7�er 77 i nchie5 0�C r^a`r r�\ in bc65 4ia.r) ay hot,,
eau 5le�d �P/oodi 4-i)rov hmCf 'ALB 2re-9 Thy PI,cn'ps
G©aL d ryo`F i;ta rid (e all Oh e -' I ©t•J. 4L e9ju4 p m ercff wec 5
As a reprbsentativeTor`tfie'responsible party, I certify that the information contained in this report is true and accurate to
Person submitting claim: �j e �{-� � Crl� l� {�1
Signature: jy{�� /C�ff� �/ Title P&T+
Telephone Number: Z$ r 3 2Z S0Q_,57
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within
five days of first knowledge of the Bypass with reference to the incident number (the incident number is only generated
when electronic entry of this form is completed, if used).
W WTP-Bypass/Upset Form May 20, 2008 02:40 PM Page 1