NC0020401_Report_20200206

Form WWTP-BYPASS/UPSET
Treatment Plant (WWTP) Bypass/Upset Reporting Form 5 Day Report
PART
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 : 11 QUO to I (Always use treatment plant permit number)
Facility: _ Notr;}t&5+ WfVJT-1P_�
Owner: ct'�w Off' [%l�dc4pr!y
If
City: lkI dw" NCL
Incident #
Region: LV /I�O�O�lfTe5 v i l I e°
County: l..-a 6LW b ell,
SPECIFIC location of the treatment units bypassed or where the upset occurred in the facility:
Was the WWTP compliant with permit requirements r Irl Yes ❑ No I❑� Unknown
Was samples betaken during bypass?: IL Yes ❑ No Unknown!
Inc dent Started Dt: O I Duo " w� Time: D i ar I5 f�M ncident End Dt: 1 ^ rO Z�Time:
(mmdd-yyyy) hh:mmrAM/PM (mm-dd-yyyy) hh:mm AM/PM
Estimated volume
of the Bypass/Upset:
Weather conditions during bypass/upset e�ve k�4car r t.v r �
Did Bypass/Upset reach surface waters? 0 Yes ❑ No ❑ Unknown Volume reached surface waters (gallons): &Cp
Surface water name: Fal,lingI,�r eek
Did the bypass/upset result in a fish kill? O eS o ClUnknown If Yes, estimated number of fish killed?
SPECIFIC cause(s) of the Bypass/Upset:
t he KA5 pump ds -a�Ior, l ow 1ev�1 Thal fwnconeot'
ands prevW" +he- M5 v?)p5 Ode runnfnq ^rho wcFwell
leyrl r�vse to +11e point o wvluf I - exifed the wla.r,hofe, The
olpw or C�n ALA V 41v"e-d on & 5par'e pvtrnp etnc(( ilovoed +he RA5
otown an 41 4o e 41caf 51+vaA-10r, W a5 eorre d ec( -
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:
Signature: . Title pietrrr Suerin l rndenf
Telephone Number.
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).
WWTP-Bypass/Upset Form May 20, 2008 02:40 PM Page 1