NC0025542_Report_20200327

Form WWfP-BYPASS/UPSET
Treatment Plant (WWfP) Bypass/Upset Reporting Form 5 Day Report
PART I
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� nC�55�fa (Always use treatment plant permit number)
Facility: COAr`Wba (^JwT.a Incident#
Owner: t,4f a-f `CKnL/ Region: mry�)`PS0IIe
City: Cck -V(N W h County: raja W ba
SPECIFIC location of the treatment units bypassed or where the upset occurred in the facility:
Pjr%c% 4 nfa;n ;llnobnC(j r�
Was the WWTP compliant with permit requirements? 0 Yes ❑ No 0Unknown
Was samples be taken during bypass?: 0 Yes 0 No UnknowrD
Incident Started Dt: Qa/d5/QbZ Time: M— Incident End Dt: r Time: '
(mm-dd-yyyy) hh:mm AM (mm-dd-yyyy) hh:mm A PM
Estimated volume of the Bypass/Upset:
Describe how the volume was determined
Weather conditions during bypass/upset e
Did Bypass/Upset reach surface waters? ILI Yes I I No I I Unknown
Surface water name:
Did the bypass/upset result in a fish kill? ❑Yes No I_Vnknown If Yes, estimated number offish killed?
SPECIFIC cause(s) of the Bypass/Upset: (0yh-r 1e Swe•1ck Inj Process fan Ks -►-h'e Plani
drain Pump 64ai,on mal-uitci 11oned Cau51r5 -fhe Pat-{ICA.IIy +rested
"5-ke ckk Je4 iC Corn 014 o+ }he fan f dram manhole
Volume reached surface waters (gallons): 3��
As a
representative for
the
responsible
party,
I certify that the
information contained in this report is true and accurate to
t e
est d my now a
ge.
Person submitting claim: VOSh t'ItY I-Mf7).L
IIT
Signature: Title b ri L
Cr
Telephone Number: %ail d 34 _ 29 19
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 Farm May 20, 2008 02:40 PM Page 1