WQCS00120_Regional Office Historical File Pre 2018 (3)

ROY COOPER
Govemor
MICHAEL S. REGAN
Secretory
S. DANIEL SMITH
Dlrecror
NORTH CAROLINA
Environmental Quality
CERTIFIED MAIL #: 7018 0360 0002 2099 1079
RETURN RECEIPT REQUESTED
July 16, 2020,
Todd Herms, Manager Town
Town of Maiden
19 N Main Ave
Maiden, NC 28650
SUBJECT: NOTICE OF VIOLATION
Tracking Number: NOV-2020-DV-0327
Sanitary Sewer Overflows - June 2020
Collection System Permit No. WQCS00120
Maiden Collection System
Catawba County
Dear Mr. Helms:
1
FILE
The self -reported Sanitary Sewer Overflow (SSO) 5-Day Report submitted by Town of Maiden indicates violations
of permit conditions stipulated in the subject permit and North Carolina G.S. 143-215.1. Violations include failing to
effectively manage, maintain, and operate the subject collection system so that there is no SSO to the land or
surface waters and making an outlet to waters of the State for purposes of G.S. 143-215.1(a)(1), for which a
permit is required.
Specific incident(s) cited in the subject report include the following:
Total Vol
Total Surface
Incident Start Duration Vol Water
Number Date (Mina) Location. Cause (Gals) (Gals) DWR Action
202002121 6/30/2020 109 15 West Holly Street Debris in line 950 950 ; Notice of Violation
North Crvoina D-partmer.t of E ; ronm-ntal Quafty. I Do.,s»n oflr.ater Rasovr es
D_E Moorezylzz Reg ona! Offioe 1 610 Eat Center Avenue, Su le 201. 1 ?VwresvlEe. k1orth Carofina 28115

Remedi8l=a'Etions„if not,'
lready implemented, should be taken to correct the above noncompliance. Please submit
a written rdspoh4to this Notice of Violation. Your response is to be received by the regional office within 15
business days following receipt of this violation. Please include any additional documentation about this incident(s)
in the response. The submittal will be considered in determining whether the Division will assess a_ civil penalty for
the cited violations.
If you have any questions, please do not hesitate to contact Michael Meilinger or me with the Water Quality Section
in the Mooresville Regional Office at 704-663-1699 or via email at [e-mail] or
Corey. basinger@ncdenr,gov.
Sincerely,
DocuSigned by:
A14CC681 AF27425...
W. Corey Basinger, Regional Supervisor
Water Quality Regional Operations Section
Mooresville Regional Office
Division of Water Resources,- NCDEQ
Cc: Mooresville Regional Office - WQS File
Central Files, Water'Quality Section
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$ TOWN OF MAIDEN'
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C3
sh MAIDEN NC 28650
ATTN: TODD HERMS, TOWN MANAGER ------
dwr/mm 7/17/2020
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RECEIVEDINCDENR/DWR Laserfiche
JUL G Pi 2020 Form CS-SSO
WQROS
Collection System Sanitary Sewer Overflow Reporting Form
' MOORESVILLE REGIONAL OFFICE PART
This form shall be submitted to the appropriate DWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number t4cge'5ooi8a (WQCS# if active, otherwise use treatment plant NC/WQ#)
Facility: Jrr3 ©F >MA101w Incident #
Owner: —a W RS C1= )MA t eCw7 Region:
City: mat fcu County: CATA LJSA
Source of SSO (check applicable) : ® Sanitary Sewer ❑ Pump Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation - i.e. Pump Station 6,
Manhole at Westall & Bragg Street, etc.) : WAHOL-9 # 5 - 110 - ) $S'
Latitude (degrees/minute/second):
Incident Started Dt: aa Time- M' a7 Ev"
(mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: 9M3 gallons
Longitude(degrees/minute/second)
Incident End Dt: 1=10— Time- 1' 110 PT
(mm-dd-yyyy) hh:mm AWPM
Estimated Duration (Round to nearest hour). C2
Describe how the volume was determined: FIP-'`1 IBC & Nmliz
Weather conditions during SSO event: SU ouV
Did SSO reach surface waters? & Yes 0 No ® Unknown Volume reaching surface waters (gallons):
Surface water name: Uw1KAJ2W64
Did the SSO result in a fish kill? ® Yes ® No ® Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
El Severe Natural Condition 13 Grease 0 Roots
Inflow and Infiltration p® Pump Station Equipment Failure El Power outage
Vandalism Debris in line ❑ Other (Please explain in Part II)
Immediate 24-hour verbal notification reported to: loon aQis.cm
= DWQ '^ ' Emergehcy Mgmt. Date (mm-dd-yyyy):-& 1 1.29% Time (hh:mm AM/PM): t%;p) Pm
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a ress release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county w er e discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are reauired to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permiftee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form ' October 9, 2003 Page 1

01
Form CS-SSO
i Collection System Sanitary Sevier Overflow Reporting Form
PART I I
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 SECTIONS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN PART 1
In the check boxes below, NA = Not Applicable and NE = Not Evaluated
A HARDCOPY OF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWQ REGIONAL OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Severe Natural Condition (hurricane, tornado, etc.)
Describe the "severe natural condition" in detail.
How much advance warning did you have and what actions were taken in preparation for the event?
Comments:
Grease (Documentation such as cleaning, inspections, enforcement
actions, past overflow reports, educational material and distribution date,
etc, should be 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 trapstinterceptors? OYesO No ONA ONE
Have there been recent inspections and/or enforcement actions taken on nearby restaurants or other OYe,O No ONA ONE
nonresidential grease contributors?
Explain.
Have there been other SSOs or blockages in this area that were also caused by grease? ElYesO1 No ®NA ®NE
When?
If yes, describe them:
Have cleaning and inspections ever been increased at this location? ❑YesO No ONA ONE
Explain.
CS-SSO Form October 9, 2003 Page 2

Have educational materials about grease been distributed in the past?
❑Yes❑ No❑NA❑NE
When?
and to whom?
Explain?
If the SSO occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation?
Were the floats clean?
Comments:
Roots
Do you have an active root control program?
Describe
❑Yes❑ No❑NA❑NE
❑Yes❑ No❑NA❑NE
Have cleaning and inspections ever been increased at this location because of roots? ❑Yes❑ No ❑NA ❑NE
Explain:
What corrective actions have been accomplished at the SSO location (and surrounding system if
associated with the SSO)?
What corrective actions are planned at the SSO location to reduce root intrusion?
Has the line been smoke tested orvideoed within the past year? ❑Yes❑ No❑NA❑NE
If Yes, when?
Comments:
Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule in any permit that ❑Yes❑ No ❑NA ❑ NE
addresses I!I?
CS-SSO Form October 9, 2003 Page 3

As a representative for the responsible party, I certif that the information contained in this report is true and accurate
to the best of my knowledge.
Person submitting claim:
Signature: . AmAj-
-
Telephone Number: 828 - LI.-g - Sp30
Date: Z,/,:30 1 S3®
Title: 560-VIe9 rLCH
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five 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).
CS-SSO Form October 9, 2003 Page 8

r AL
Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# 00 U
Incident Number from BIMSC�
Incident Reviewed (Date):
Incident Action Taken: BPJ
V NOV-2009-DV O i S
Spill Date Time 8 % M am pm�
Reported Date Time C)b am 0
Reported To SWP Staff or EM Staff
Reported By rp_ A9,CSL_ Phone
Address of Spill
Aoo). - O_a4,a_Lm,
County (h&cAq Cityclostic)
Cause of Spill
Total Estimated Gallons ®Q Est. Gal to Stream r7 vs
Stream Fish Kill: Yes No Number Species_
Non Required Information and other comments relating to SSO incident:
Response time
m i,n utes
Zone
Map Quad

Z
°. Form CS-SSO
L{'6 •-
E R` Collection System Sanitary Sewer Overflow Reporting Form
APR PART
This form shall be submitted to the appropriate DWQ Regional Office within five daysof the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number: I`+ i.'I, e,.� `• �ls
vt�G,egyi�l��isWt@nent plant NC/WQ#)
„i4
Facility: _0� _e n Incident # 1 _ Z®
09
Owner. 4 (� t;r Region:
City: me, . eo County: 1el Gd f) ('
Source of SSO (check applicable) : ' "—'sanitary Sewer ® Pump Station
SPECIFIC location of the SSO (be consistent in descrip ion from past reports or documentation - i.e. Pump Stajiion 6,
Manhole at Westall & Bragg Street, etc.) : '-r_n� NG (',ran fY1; PIS t"�; c,�1$
Latitude (degrees/minute/second):
Incident Started Dt: � ) Time- V` 10
(mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: 2�' 00 gallons
Describe how the volume was determined:
Weather conditions during SSO event: —
Did SSO reach surface waters?
Surface water name:
Did the SSO result in a fish kill?
Longitude(degrees/minute/second)-
Incident End D• 3 I Time- L 0 2 00)
(mm-dd-yyyy) hh:mm AM/PM
Estimated Duration (Round to nearest hour`- io
GI
n It- f�_-a-o- f
fii) o ouer Fjo6"l
11 r
YesE3No® Unknown Volume reaching surface waters (gallons): -- 0 -
❑ Yes [E No ❑ Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
❑ Severe Natural Condition ❑ Grease
❑ Inflow and Infiltration E❑ Pump Station Equipment Failure
❑ Vandalism ❑ Debris in line
Im iate 24-hour verbal notification reported to: ` (! cc (- bir ctF71 F
u DWQ ❑ Emergency Mgmt. Date (mm-dd-yyyy): �j % i )
1_1 Roots
❑ Power outage
Other (Please explain in Part II)
09 Time (hh:mm AM/PM): D.: g 0
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the dikharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reoorted to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003 Page 1

e
Have educational materials about grease been distributed in the past?
11 YesD No ❑ NA 11 NE
When?
and to whom?
Explain?
If the SSO occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation?
'Alere the floats clean?
Comments:
Roots
Do you have an active root control program?
Describe
r V 1 �t-- it, .�
Have cleaning and inspections ever been increased at this location because of roots?
Explain:
[]Ye,Cl W EI NA IINE
B YeO No i_J NA ® NE
What corrective actions have been accomplished at the SSO location (and surrounding system if
associated with the SSO)?
What corrective actions are planned at the SSO location to reduce root intrusion? !
i L) ( 0 0 ` C'0'14 o Dos s e - n6A nT 00r
Has the line been smoke tested or videoed within the past year?
If Yes, when?
Comments:
Inflow and Infiltration
YesU No
No LJ NA L_1 NE
Are you under an SOC (Special Order by Consent) or do you have a schedule in any permit that OYeE No ONA IIL" 1NE
addresses 1/1?
CS-SSO Form October 9, 2003 Page 3

JAb
4b
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: Derv'%V flex c-< Date: JCj
Signature: Ci `Y`ry -� I �--e Title: �'''� j
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 SSO with reference to the incident number (the incident number is only generated when electronic entry of this form
is completed, if used).
CS-SSO Form October 9, 2003
Page 8

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#
(0-0 � -�;z_ CD
Incident Number from BIMS 201400 "13./
Incident Reviewed (Date):
Incident Action Taken
NOV-2014-DV
DV-2014-
�) L9 — sp� Ct W
q�
—_�
Spill Date 2ai `k Time ®'a .So � pm o`� • i °1VA.
Reported Date .ITi`-� Time �5 am/4Z!)
Reported To SWP Staff or EM Staff
Reported By �� VV °�� ���� Phone c>
Address of Spill3�
County <21 G`` City
Cause of Spill
R 'r�
Total Estimated Gallons --:22S 0—� Est. Gal to Stream
Stream 'Z-�"i tV"'K<-k Fish Kill: Yeses— lumber Species,
Non Required Information and other comments relating to SSO incident:
Response time
minutes
Zone
Map Quad
414V

I
REGEtVED State of North Carolina
1114%iS1ON OF nr rTR QUALITY Department of Environment and Natural Resources
y
3 f Division of Water Resources
APR Collection System Sanitary Sewer Overflow Deporting Form
Dlvision of Water Resources _ Form CS-SSO
PART I:
This form shall be submitted to the appropriate DWR Regional Office within five days of the first knowledge of the sanitary
sewer overflow (SSO).
Permit Number: WQCS00120 (WQCS# if active, otherwise use WQCSD#)
Facility: Town of Maiden Incident #: 201400739 Owner: Todd Herms
Region: Mooresville City: Maiden County: Catawba
Source of SSO (check applicable): ® Sanitary Sewer , ❑ Pump Station / Lift Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation - i.e. Dump
Station 6, Manhole at Westall & Bragg Street, etc.): Manhole behind 534 South D Ave. Extension
Manhole #: N/A
Latitude (degrees/minute/second): 81/13/25.11 Longitude (degrees/minute/second): 35/34/17.86
Incident Started Dt: 04-14-2014 Time: 08:50 AM Incident End Dt: 04-14-2014 Time: 09:10 AM
(mm-dd-yyyy) (hh:mm) AM/PM (mm-dd-yyyy) (hh:mm) AM/PM
Estimated volume of the SSO: 2500 gallons Estimated Duration (round to nearest hour): 1 hour(s)
Describe how the volume was determined: Visual
Weather conditions during the SSO event: Cloudy
Did the SSO reach surface waters? ® Yes ❑ No ❑ Unknown
Volume reaching surface waters: 500 gallons Surface water name: Shady Branch
Did the SSO result in a fish kill? ❑ Yes ® No ❑ Unknown
If Yes, what is the estimated number of fish killed? N/A
SPECIFIC cause(s) of the SSO:
❑Severe Natural Conditions ❑ Grease
❑Pump Station Equipment Failure ❑ Power Outage
❑Other (Please explain in Part II)
®Roots ❑Inflow & Infiltration
❑Vandalism ❑ Debris in line ❑Pipe Failure (Break)
24-hour verbal notification (name of person contacted): James Bealle
®DWR ❑Emergency Management Date (mm-dd-yyy): 04-14-2014 Time: (hh:mm AM/PM): 16:45
If an SSO is ongoing, please notify the appropriate Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1C(b), the responsible party of a discharge of 1,000 or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing
general coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated
wastewater enters surface waters, a public notice shall be published within 10 days and proof of publication shall be
provided to the Division within 30 days. Refer to the reference statute for further detail.
The Director, Division of Water Resources, may take enforcement action for SSOs that are required to be reported to
Division unless it is demonstrated that:
1) the discharge was cause by sever natural conditions and there were no feasible alternative to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of
the Permittee and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the
basis for the determination of any enforcement action. Therefore, it is important to be as complete as possible
WHETHER OF NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED SEE PAGE 13
Form CS-SSO Page 1

0

System Visitation
ORC
Backup
Name: Brian Walker
Certification Number: 999200
Date visited: Daily (Monday -Friday)
Time visited: 7:00 AM74:00 PM
How was the SSO remediated (i./e. Stopped and cleaned up)?
Ow
A crew was called to bring our sewer flusher to the location. Our pumper truck was also dispatched to this location. The
pumper truck arrived on the scene before the jetter so we immediately started pumping from the manhole that was
overflowing to stop the SSO. Once our jetter arrived we jetted from the down stream manhole and was unable to get
through the blockage. We then videoed the line and discovered a large root ball, we then put our root cutter on our jetter
and after about 1 hour were able to get through the blockage. The line was videoed a second time to confirm that all of the
roots were removed.
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: Brian Walker
Date: 04/14/2014
Signature:��Ns::Z7- �� li� Title:
Telephone Number: 828-428-5030
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five
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

9ov
Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# 0 0 t 7-�b
Incident Number from BIMS 2013012-` -3
Incident Reviewed (Date):
Incident Action Taken: BPJ
Spill Date 1\2 �2-0 t3
Reported Date 11 1 2. .7,013
NOV-2013-DV
DV-2013-
Time am/0
Time 3,570 am/(ff)
Reported To SWP Staff or EM Staff a-(
Reported By S-ri aAA. wa 1UN' Phone R 1.$ LO-$ S 09 0
Address of Spill 103 N A ql ^ a�ye-4, .
County
'Cause of Spill Qoo 1-S
City HoLiman.
Total Estimated Gallons 50 Est. Gal to Stream P1Utcrr
Stream �.,'�'Fish Kill: Yes ®o Number Species_
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad
N ev s*

RECEIVED State of North Carolina
DIVISION OF WATER QUALITY
Department of Environment and Natural Resources
DEC o 6 2013 Division of Water Resources
®
l � SVIlP SECTION Collection System Sanitary Sewer Overflow Reporting Form
vision of Waaterter Resources MOORESVILLE REGIONAL OFFICE Form CS-SSO
PART I:
This form shall be submitted to the appropriate DWR Regional Office within five days of the first knowledge of the sanitary
sewer overflow (SSO).
Permit Number: WQCS00120 (WQCS# if active, otherwise use WQCSD#)
Facility: Town of Maiden Incident #: 201302223 Owner: Todd Herms
Region: Mooresville City: Maiden County: Catawba
Source of SSO (check applicable): ® 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 Westall & Bragg Street, etc.): Manhole in front of 103 North 10" Ave.
Manhole #: N/A
Latitude (degrees/minute/second): Longitude (degrees/minute/second):
Incident Started Dt: 11/27/2013 Time: 2:45 PM Incident End Dt: 11/27/2013 Time: 3:05 PM
(mm-dd-yyyy) (hh:mm) AM/PM (mm-dd-yyyy) (hh:mm) AM/PM
Estimated volume of the SSO: 50 gallons Estimated Duration (round to nearest hour): 1 hour(s)
Describe how the volume was determine : "Visual
Weather conditions during the SSO eventSunny
Did the SSO reach surface waters? ® Yes ❑ No ❑ Unknown
Volume reaching surface waters: 50 gallons Surface water name: Un-named stream that feeds into Maiden
Creek
Did the SSO result in a fish kill? ❑ Yes ® No ❑ Unknown
If Yes, what is the estimated number of fish killed? N/A
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-hour verbal notification (name of person contacted): Sujatha
®DWR [--]Emergency Management Date (mm-dd-yyy): 11/27/2013 Time: (hh:mm AM/PM): 03:15 PM
If an SSO is ongoing, please notify the appropriate Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1C(b), the responsible party of a discharge of 1,000 or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing
general coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated
Wastewater enters surface waters, a public notice shall be published within 10 days and proof of publication shall be
provided to the Division within 30 days. Refer to the reference statute for further detail.
The Director, Division of Water Resources may take enforcement action for SSOs that are required to be reported to
Division unless it is demonstrated that:
1) the discharge was cause by sever natural conditions and there were no feasible alternative to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of
the Permittee and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the
basis for the determination of any enforcement action. Therefore, it is important to be as complete as possible
Form CS-SSO Page 1

0
Roots
Do you have an active root control program on the line / area in question? ❑ Yes ® No ❑NA ❑ NE
Describe:
Have cleaning and inspections ever been increased at this location because
of roots? ❑ Yes ® No ❑NA ❑ NE
Explain:
What corrective actions have been accomplished at the SSO location (and
surrounding system if associated with the SSO)? Roots were cut out of the main line to prevent a new blockage.
What corrective actions are planned at the SSO location to reduce root intrusion? We will treat this line with Dukes Root
Control
Has the line been smoke tested or videoed within the past year? ❑ Yes ® No ❑NA ❑ NE
If Yes, when?
Comments:
Form CS-SSO
Page 6

Other (Pictures and police report, as applicable, must be available upon request.)
Describe:
Were adequate equipment and resources available to fix the problem? ® Yes ❑ No ❑NA ❑ NE
If Yes, explain: A Crewe was called to bring our sewer flusher to the location. When the crew arrived on site they
immediatly jetted from the down stream manhole and cleared the blockage. Our pumper truck was also in route
to the location but was not needed.
If the problem could not be immediately repaired, what actions . ❑ Yes ❑ No ®NA ❑ NE
were taken to lessen the impact of the SSO?
Comments: The spill was flowing out of a manhole at 103 North I Oh Ave and was running into a stormdrain that runs
into a back yard where there was a buffer from the unnamed stream.
Form CS-SSO Page 12

System Visitation
ORC ® Yes
Backup ® Yes
Name: Brian Walker
Certification Number: 999200
Date visited: Daily (Monday -Friday)
Time visited: 7:00 AM-4:00 PM
How was the SSO remediated (i./e. Stopped and cleaned up)?
A crew was called to bring our sewer flusher to the location. When the crew arrived on site they immediatly jetted from
the down stream manhole and cleared the blockage. Our pumper truck was also in route to the location but was not needed.
Lime was put out over the spill area.
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: Brian Walker Date: 11/27/2013
Signature: Title: Q _
Telephone Number: 828-428-5030
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five
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 14

it .k
Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# bOlo�
Incident Number from BIMS _ 20130 / S 7
Incident Reviewed (Date):
Incident Action Taken: ✓ BPJ
NOV-2013-DV a `
DV-2013-
irrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr®rrr�rrrrrrrrerrrrrrrrrrrrrrrrrrrrrrrrr■
Spill Date I/,
Time J� Od
%A
t� S
� q��A_9_
ly
I
C/" �,6L
.A
00
am/( WOJ,r. �µ
Reported Date �� Time 10 = 1( amo
Reported To SWP Staff or&iStaff CGu�ioel-9
Reported By A4 U�,.&Q Phoneg'
%g�_ 31a
Address of Spill LU,= tiF4,10.-
County Oa4WL&L_) City Cuc
Cause of Spill &lA°
Total Estimated Gallons Ll 00 Est. Gal to Stream
Stream. 6" r .1,& Fish Kill: Yes No Number
Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad
4,,�ao iaww alfa":,�f -
V�( ;,-V
1�94 I(-

North Carolina Emergency Management - EM43 Reporting
�w
North Carolina Emergency Management - EM43 Reporting
Print Return To List
EM Level:
NCEM Edited:
Include in Report:
4
Yes
Yes
Taken by:
Date/Time Reported:
Date/Time Occurred:
J Childs
08/22/2013 22:11:27
08/22/2013 15:00:27
Reported by:
Agency:
Phone:
Brian Walker
Maiden PW
828-428-5030
County:
City:
Area:
Catawba
Maiden
13
Street Address:
Zip Code:
Type: Wastewater
Animal Disease Event Type:
Complaint Event Type:
FNF Event Type:
HazMat Event Type:
Homeland Security Event:
Other Event Type:
Transportation Event Type:
Weather Event Type:
State Resource Request
*VJ;QThaCAa"
Bomb Threat Event Type:
Fire Event Type:
FNF Class:
HazMat Class:
Non-FNF Event:
SAR Type:
Wastewater Event Type:
Sewage
Weather Event Name:
HazMat Mode:
Non-FNF Event Type:
WMD Event Type:
Pagel of 3
Event Description:
Local utility reported that 900 gallons of wastewater was released into Clarks Creek, not a source of
drinking water, due to an aerial line leak. Line was plugged and contractor conducted cleanup. No
state resources requested.
Filename:
Deaths: Injuries: Evacuation: Radius:
0 0 0 0
Responsible Party: Responsible Party Phone:
Point of Contact: Point of Contact Phone:
Latitude: Longitude:
00.000000-00.000000
RRT Request: RRT Approved: RRT Team
RRT Mission
https://www.ncsparta.net/eoc7/boards/board.aspx?tableid=275&viewid=1011 &label=EM-... 8/26/2013

Of VJArjj9 RECEIVED
L19`JIS?0N (2L!AI ITY
` Form CS-SSO
c rt A U G G 2 013 Collection System Sanitary Sewer Overflow Reporting Form
PART
This form shall be submitted to 'appropriate; DWQ�Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number: �(CS WI 20 (WQCS# if active, otherwise use treatment plant NCNVQ#)
Facility-_ Qn a 1E Ma� m Incident# QS
Owner: Loc�ci �1DIr�n� Region: M.Dct25v : \\ e-
City: County: C-GA01"S
Source of SSO (check applicable) : VSanitary Sewer 0 Pump Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation - i.e. Pump Station 6,
Manhole at Westall & Bragg Street, etc.) : W 11 W a-sk rnaLrton (?c4 • USA<- CLU ry 0-*-R-,k 1:
'So/ 5 . ��N��'Lol'h,agrees/minute/second): Lnf, %actw. degrees/minute/second)•8` 14' I.�iwes+
Incident Started Dt: Q -6 - 22 - Time- 0-6bO R 11A Incident End Dt- Cg - 22 - 20%'S Time- Q S 3 D PM
(mm-dd-yyyy) hh:mm AM/PM (mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: o a gallons Estimated Duration (Round to nearest hours 3
Describe how the volume was determined: < L'ne- 6Syag v 1� i}1� �r ��` �St � c� r, a�� s- I�ra�s 10zr rY•: a� .
Weather conditions during SSO ev�e--n�t/
Did SSO reach surface waters? I Yes ❑No Unknown Volume reaching surface waters (gallons): CkC0 \g
Surface water name: -pia` � U' eeK �—
Did the SSO result in a fish kill? ❑ Yes Q< ❑ Unknown If Yes, what is the estimated number of fish killed?.
SPECIFIC rcaauuse(s) of the SSO:
2�1 Severe Natural Condition ❑ Grease ❑ Roots
[I Inflow and Infiltration ❑ Pump Station Equipment Failure ❑ Power outage
❑ Vandalism ❑ Debris in line ❑ Other (Please explain in Part II)
Immediate 24--hhoour/verbal notification reported to: CAN, �d s
❑ DWQ E Emergency Mgmt. Date (mm-dd-yyyy): 9 . � 2 - ),013 Time (hh:mm AM/PM): IC) , ( i 0 rA
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to'all print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003 Page 1

Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
PART I I
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 SECTIONS 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 DWQ REGIONAL OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Severe Natural Condition (hurricane, tornado, etc.)
Describe the "severe natural condition" in detail.
FJ,Qpdyae,-te;,; +.�Qs d a \acac area N� ea�l% Sodom ear -r1n a-P &I_ kc.c$$ frees wa�shec9 onb fhe cAer�p�
How much advance warning did you have and what actions were taken in preparation for the event?
Comments:
Grease (Documentation such. as cleaning, inspections, enforcement
actions, past overflow reports, educational material and distribution date,
etc. should be 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 traps/interceptors? ❑YX No ❑NA ❑NE
Have there been recent inspections and/or enforcement actions taken on nearby restaurants or other []Yes[] No [INA Q NE
nonresidential grease contributors?
Explain.
Have there been other SSOs or blockages in this area that were also caused by grease? []Yes[:] No ❑NA ONE
When?
If yes, describe them:
Have cleaning and inspections ever been increased at this location? ❑YesO No ❑NA ❑NE
Explain.
CS-SSO Form October 9, 2003 Page 2

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: GC i c+n 'V4 q\ke l
Signature:
Telephone Number: 1g21g- y •Z9,_ Sc)3 a
Date: Eo22-1-0t3
Title: (92L
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five 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).
CS-SSO Form October 9, 2003 Page 8

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# C1I CIO
Incident Number from BIMS 20130L'Ia
Incident Reviewed (Date):
Incident Action Taken: 1/ BPJ
NOV 2013=DV - — - -
Time Date
r
Address of .Spill t
County A-j City W�k
Cause of Spill VC> LA,� I (' \i) hr� jJ
Total Estimated Gallons Est. Gal to Stream ' L
Stream �,Fish Kill: Yes(N)Number—Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

Permit#
Owner and Facility Name
WQCS00253
Bradfield Farms Water Company CS
WQCS00196
Carolina Water Service Cabarrus Woods CS
WOCS00233
Carolina Water Service Hemby Acres CS
WQCS00001
Charfotte-Mecklenburg CS
WQCS00016
City of Albemarle CS
WQCS00046
City of Belmont CS
WOCS00107
City of Bessemer City CS
WOCS00089
City of Cherryville CS.
WQCS00221
City of Claremont CS
WQCS00326
City of Concord CS
WQCS00088
City of Conover CS
WQCS00017
City of Gastonia CS
WOCS00020
City of Hickory CS
WQCS00327
City of Kannapolis CS
WQCS00036
City of Kings Mountain CS
WQCSOD040 '
City of Lincolnton CS
WQCSOD164
City of Lowell CS
WQCS00026 ,
City of Monroe CS
WQCSDO059
City of Mount Holly CS
WQCS00044
City of Newton CS
WQCS00019
City of Salisbury CS
WQCSDO037
City of Shelby CS
WOCS00030 -
City of Statesville CS
WQCS00149
East Lincoln CS
Deemed Permitted
Permit#
Owner and Facility Name
WQCSDO130
Brooks Food Group -Brooks Food Group
WQCSDO114
Charlotte Mecklenburg Schools - Misc Laterals
WQCSDO057
City of High Shoals CS
WQCSDO117
Duke Energy Marshall Steam Station
WQCSD0257
Fallslon -
WQCSDO116
Gopse Creek Utilities Fairfield Plantation WWTP
WQCSDO101
Harborside Dev LLC-Midtown T CS
WQCSDO095
Kennedy Dev..Group LLC-Boardwalk Villas CS
WQCSDD098
Kennedy Dev, Group LLC-Kings Point CS
WQCSD0105
Kennerly Dev. Group LLC-Moon Bay Condos CS
WQCSDD107
Kennedy Dev- Group LLC-Schooner Bay CS
WQCSDO099
Kennerly Dev. Group LLC-Spinnaker Point CS
WQCSD0258
Kingstown
WQCSDO112
Lake Norman -South Point CS
WOCSDO104
Lake Norman -Villas S Harbour CS
WQCSDO102
Lake Norman -Vineyard Pt Resort CS
Permit #
Owner and Facility Name
'WQCS00171
Greater Badin CS
WQCS00322
Aqua Country Woods East CS
WQCS00222
Town of Boiling Springs CS
WQCS00341
Town of China Grove CS
WQCS00231
Town.of Cleveland CS
WQCSOD058
Town of Cramedon CS
WQCS00165
Town of Dallas CS
WQCS00342
Town of E. Spencer CS.
WQCS00328
Town of Harrisburg CS
WQCSOD343
Town of Landis CS
WQCS00310
Town of Longview CS
_WQCSOD-120--
Town of Maiden CS
WOCS00344
Town of Marshville-CS
WQCS00043
Town of Mooresville CS
WQCS00125
Town of Mt Pleasant CS,
WOCSOD153
Town of Norwood CS
WQCS00190
Town of Oakboro CS
WOCS00325
Town of Stanfield CS
WQC800180
Town of Stanley CS
WOCSOD135
Town of Taylorsville CS
WQCS00258
Town of Troutman CS
WQCS00345
Town of Wingate CS
WQCSOD054
Union County CS
WQCS00009
WSA Cabarrus Co. CS
Permit#
Owner and Facility Name
WQCSDO064
Lincoln County CS
WQCSDO097
Martin Dev Gp-N Point & Portside CS
WQCSDO120
Martin Marietta Mallard Creek
WQCSDO019
Town of Richfield CS
WQCSDOD24
Town of Grover CS
WOCSDO038
Town of McAdenville CS
WQCSD0002
Town of Ranlo CS
WOCSDO049
Town of Spencer Mountain CS
WOCSDO252 All spills which do not have a permit
number assigned
1

RECEIVED
t7IV;Sjoll C'y= 1I1,,17ER.QUALITY)
T AG MAR Y I Z013 Form Cs-SSO
orL-C,-f10N ClO�lection System Sanitary Sewer Overflow Reporting Form
Iwr�► � M®ORES°a°ii.LE f ���l�I��.yL oFF t V 112009 fig✓ PART .
rf
This form shall be submitted.to the appropriate DWQ Regional Office within five days of the first knowledge of:
the sanitary sewer overflow (SSO).
Permit Number: �n�(WQCS# if active, otherwise use WQCSD#)
Facility: �m�% ®� >t � n c de n Incident #
Owner: MWA C n - -Cedd Region: M M
City: County:
Source of SSO (check applicable) : Sanitary Sewer ❑ pump Station /Lift Station
SPECIFIC location of the SSO (be consistent in description from p ArePPorts or documentation - i.e. Pump Station 6, AA
Manhole at Westall & Bragg Street, etc.) :' riiQn hoic ISCnatC.k O SSO s06 k 'b.
Manhole#
Latitude (degrees/minute/second):
Incident Started Dt: 01- OS- 2013 Time: M
(mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO:. SS gallons
Describe how the volume was
Weather conditions during SSO event: NA41 W%'
Did SSO reach surface waters? Wes ❑ No❑
Surface water name:
Longitude(degrees/minute/second):
Incident End Dt: 03.05.2013 . Time: 12 '• IS In
(mm-dd-yyyy) hh:mm AM/PM
Estimated Duration (Round. to nearest hour):
Volume reaching surface waters (gallons): LAGO
Did the SSO result in a fish kill? ❑ Yes AQ No0 Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
❑ Severe Natural Condition ❑ Grease ❑ Roots
❑ Inflow and Infiltration Pump Station Equipment Failure ❑ Power outage
❑ Vandalism 0,15ebris in line ❑ Other (Please explain in Part 11)
❑ Pipe Failure (Break)
24-ho erbal notification (name of person contacted) �®n�
DWQ ❑ Emergency Mgmt. Date (mm-dd-yyyy):03'05.2013Time (hh:mm AM/PM)- Z
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the countyw er—fi a the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the —refdr—e—ncFed statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is aemonstratea tnat:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part 11 must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it1s important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form Page 1

Debris in line (Rocks, sticks, rags and other items not allowed in the collection system, etc.)
What type of debris has been found in the line?
cause or source of debris.
Are manholes in the area secure and intact?
When was the area last checked/cleaned?
No ❑ NA❑ NE
12-0-'1-1.012
Have cleaning and inspections ever been increased at this location due to previous problems with debris? ❑ YeVN ❑ NA❑ NE
Explain:
Are appropriate educational materials being developed and distributed to prevent future similar QKeEO No ❑ NAQ NE
occurrences?
Comments:
M&A w i-% Plan + Sstn e(y ►s o r an 3-1- 2013
CS-SSO Form Page 11

System Visitation
ORC
Backup
Name:
Cert#
Date visited:
Time visited:
es
�i°1y58 �
03 --cs5 •'1,p�3
I1:55 AY-%
How was the SSO remediated (i.e. Stopped and cleaned up)?
SealQr :1e +i r oar -Tr", Saekha t % Dumb -Erg- Lim c
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: "'& 10,Y1 W Ct1r-t Date:03- QS- zo 13
SignatLTlr: a Title:
Telephone. Number: 2�' - 312 `4 q 3S
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five 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).
l
CS-SSO Form Page 15

The Town of Maiden pretreatment coordinator called a meeting with our management contacts at
Ethan Allen. We scheduled this meeting after we had a sewer overflow on 03/05/13 with a line that was
a few hundred yards behind their facilities that they discharge into. We found debris, rocks, and some
rags to be the cause of the overflow. We asked the representatives from Ethan Allen about what kind
of paper towels and rags they use and how they educate their employees to their proper disposal.
They told us that in the last year they had switched to automatic paper dispensers to keep employees
from using as much paper towels. They also went to toilet paper dispensers that hold a lot more toilet
paper to keep their employees from running out of toilet paper and using the paper towels. They have
signs in the bathrooms in English asking their employees not to throw paper towels in the toilets,
however we asked them to include the same notice in Spanish. As far as the rags, they said they would
brief and educate their departments in their staff meetings to make sure these are not being disposed of
incorrectly.

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A: '.
I
Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#
Incident Number from BIMS��12 c0
Incident Reviewed (Date): ,
Incident Action Taken: �BP'Jl
NOV-2009-DV
i a a a a a■ a a. r a r a r r a r r a a a e a r r a a a o a a r a r r r Nassau r a r a r r r r a r a r r a r a a■ a a a a a a a a a a a■
Spill Date Time am/
Reported Date Time 0C� am/C—M)
Reported To SWP Staff or�MStaff
Reported By��0.3 Q�� Phone
Address of Spill
County / City
Cause of Spillr2�sS�
Total Estimated Gallons v Est. Gal to Stream L
Stream porn^ Fish Kill: Yes& Number Species_
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone . Map Quad

Permit #
Owner and Facility Name
WQCS00253
Bradfield Farms Water Company CS
WQCS00196
Carolina Water Service Caba«us Woods CS
WQCS00233
Carolina Water Service Hemby Acres CS
WQCS00001
Charlotte-PJlecklenburg CS
WQCS00016
City of Albemarle CS
WQCS00046
City of Belmont CS
WQCS00107'
City of Bessemer City CS
worsnnnR4
(Jima of C.hprNtnP rc
WQCS00221
_Ciiy_of_Claremonl..CS.__.--__
WQCS00326
City of Concord CS
WQCS00088
City of Conover CS
WQCS00017
City of Gastonia CS .
WQCS00020
City of Hickory CS
WQCS00327
City of Kannapolis CS
VVQCS00036
City of Kings Mountain CS
WOCS00040
City of Lincolnton CS
WQCS00164
City of Lowell CS
WQCS00026
City of Monroe CS
VVQCS00059
City of Mount Holly CS
WQCS00044
City of Newton CS
VVQCS00019
City of Salisbury CS
WQCS00037
City of Shelby CS
WQCS00030
City of Statesville CS'
WQCS00149
East Lincoln CS
Permit #
Owner and Facility Name
WQCS00171
Greater Badin CS
WQCS00322
Aqua Country Woods East CS
WOCS00222
Town of Boiling Springs CS
WQCS00341
Town of China Grove CS
WQCS00231
Town of Cleveland CS
WQCS00058
Town of Cramerton CS
WQCS00165
Town of Dallas CS
vVl1l..300342
I VWII UI L. JF/elll:el l.J
- -- --------.-WQCS00328 ----
Town of-Harrisburg-CS-------
WQCS00343
Town of Landis CS
WQCS00310
Town of Longview CS
WQCS00120
Town of Maiden CS
VVQCS00344
Town of Marshville CS
WQCS00043
Town of Mooresville CS
WQCS00125
Town of Mt Pleasant CS
WQCS00153
Town of Norwood CS
Deemed Permitted
Permit #
Owner and Facility Name
WQCSD0130
Brooks Food Group -Brooks Food Group
WQCSD0114
Charlotte Mecklenburg Schools - Misc Laterals
WQCSD0057
City of High Shoals CS .
WQCSD0117
Duke Energy Marshall Steam Station
WOCSD0257
Fallston
VVQCSD0116
Goose Creek Utilities Fairfield Plantation 1,%WTP
WQCSD0101
Harborside Dev LLC-Midtown T CS
WQCSD0095
Kennerly Dev. Group LLC-Boardwalk Villas CS
WQCSD0098
Kennerly Dev. Group LLC-Kings Point CS
VVQCSD0105
Kennerly Dev. Group LLC-Moon Bay Condos CS
VVQCSD0107
Kennerly Dev. Group LLC-Schooner Bay CS
WQCSD0099
Kennerly Dev. Group LLC-Spinnaker Point CS
WQCSD0258
Kingstown
VVQCSD0112 Lake Norman -South Point CS
WQCSD0104 Lake Norman -Villas S Harbour CS
WQCSD0102 Lake Norman -Vineyard Pt Resort CS
WQCS00190
Town of Oakboro CS
WQCS00325
Town of Stanfield CS
WQCS00180
Town of Stanley CS
WOCS00135
Town of Taylorsville CS
WQCS00258
Town of Troutman CS
WQCS00345
Town of Wingate CS
WQCS00054
Union County CS
WOCS00009
WSA Cabarrus Co. CS
Permit #
-__
Owner and Facility Name
VVQCSD0064
Lincoln County CS
WQCSD0097
Martin Dev Gp-N Point 8 Portside CS
WQCSD0120
Martin Marietta Mallard Creek
WQCSD0019
Town of Richfield CS
WQCSD0024
Town of Grover CS
WOCSD0038
Town of McAdenville CS
WQCSD0002
Town.of Ranlo CS
VVQCSD0049
Town of Spencer Mountain CS
WQCSD0252 All spills which do not have a permit
number assigned

North Carolina Emergency Management - EM43 Reporting
Page 1 of 3
North Carolina Emergency Management EM43 Reporting
Print Return To List
EM Level:
NCEM Edited:
Include in Report:
4
Yes
Yes
Taken by:
Date/Time Reported:
Date/Time Occurred:
J Peters
05/01/2009 22:00:44
05/01/2009 15:00:03
Reported by:
Agency:
Phone:
Damon Rice
Maiden Utilities
828-428-5000
County:
City:
Area:
Catawba
Maiden
13
Street Address:
Zip Code:
704 E Union St
Type: Wastewater
Animal Disease Event Type:
Complaint Event Type:
FNF Event Type:
HazMat Event Type:
Homeland Security Event:
Other Event Type:
Transportation Event Type:
Weather Event Type:
State Resource Request
EVENT TYPE
Bomb Threat Event Type:
Fire Event Type:
FNF Class:
HazMat Class:
Non-FNF Event:
SAR Type:
Wastewater Event Type:
Sewage
Weather Event Name:
HazMat Mode:
Non-FNF Event Type:
WMD Event Type:
Event Description:
Local utilities advised approximately 50 gallons of sewage spilled due to a grease clog.
Approximately 15 gallons spilled into a storm drain with no public drinking water source affected
and no fish kill observed. Clean up was done by raking, flushing, and applying lime to the area.
Filename:
Deaths: Injuries: Evacuation: Radius:
0 0 0 0
Responsible Party: Responsible Party Phone:
Point of Contact: Point of Contact Phone:
Latitude: Longitude:
0 0
RRT Request: RRT Approved: RRT Team
RRT Mission
http://www.ncsparta.net/eoc7/boards/board.aspx?tableid=275&viewid=1011 &label=EM-43... 5/5/2009

�g vJA rfiq `^ "ram >� *' `\
P "� Form CS-SSO
a rt
^'Coflec$lon System Sanitary Sewer Overflow Reporting Form
PART I
V1 AY U
This form shall be submitted to the appropriate DWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
cry I� _ Permit Number : � [''Si' e'v6..
(VVQ�CS6`� r�^active, otherwise use treatment plant NC/WQ#)
d ,, iF' G_�P.
Facility: n, .R r l` Pioi"jeon Incident# a ��
Owner: o n D �'1Ot �� Region: �D©�C 5 t/; ( �
City: County: COt +eta 6A
Source of SSO (check applicable) : 0 Sanitary Sewer 0 Pump Station
SPECIFIC location of the SSO (be consistent in descripti n from past reports or documentation - i.e. Pump Station 6,
Manhole at Westall & Bragg Street, etc.) : �ln 110 Le,KAzlcen 7) -7 E. ft . ') i htl E - u el •Oc7
Latitude (degrees/minute/second): Longitude(degrees/minute/second) D
Incident Started Dt: 6- I Time' 3 ' SO PN1 Incident End Dt: S 0 cl Time, , 3© P'''
(mm-dd-yyyy) hh:mm AWPM (mm-dd-yyyy) hh:mm AWPM
Estimated volume of the SSO: �D gallons Estimated Duration (Round to nearest hour):
Describe how the volume was determined: (,' S L4 Cn 1
Weather conditions during SSO event: n
W 4—
Did SSO reach surface waters? Yes 0 No 0 Unknown Volume reaching surface waters (gallons): S
Surface water name: 5 fcr, , 01- - n IRa,n 0� no -reeK
Did the SSO result in a fish kill? 0 Yes 12'No 0 Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
0 Severe Natural Condition D"Grease 0 Roots
0 Inflow and Infiltration 0 Pump Station Equipment Failure 0 Power outage
0 Vandalism 0 Debris in line 0 Other (Please explain in Part II)
Immediate 24--hourbal notification reported to:
0 DWQ ho
� Emergency Mgmt.
- SOD -- ��'K -
Date (mm- dd-yyyy): s % Time (hh:mm AM/PM): O 3Q .'00 P�
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where a the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Qualitv, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003 Page 1

�o MAIA9
Form CS-SSO
aCollection System Sanitary Sewer Overflow Reporting Form
PART I I
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 SECTIONS 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 DWQ REGIONAL OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Severe Natural Condition (hurricane, tornado, etc.)
Describe the "severe natural condition" in detail.
How much advance warning did you have and what actions were taken in preparation for the event?
Comments:
Grease (Documentation such as cleaning, inspections, enforcement
actions, past overflow reports, educational material and distribution date,
etc. should be 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 traps/interceptors?
Have there been recent inspections and/or enforcement actions taken on nearby restaurants or other
nonresidential grease contributors?
Explain.
VYeD No❑NAONE
❑YesL1CJ No❑NA❑NE
Have there been other SSOs or blockages in this area that were also caused by grease? ❑Ye No ❑NA ❑NE
When?
If yes, describe them:
Have cleaning and inspections ever been increased at this location? OYes10NoONAONE
Explain.
T LJoE4 ►d Be -fhe frs f,`m e yo h,qae heel Rj-oj.,/ems
n Ore f�o lo Inc kel PS Cq-i Sed nee, e- oe)
CS-SSO Form October 9, 2003 Page 2
j��'w vne•,f P���� dP�� Gore �n �a�c��ef Met w.`fh 0"Jaer
I? xeiri, n e_j 4o 4hem i byf

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 Date: S /�
Signature: Title: 0 R C"
Telephone Number: (5a$- SooD
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five 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).
CS-SSO Form October 9, 2003 Page 8

UNION ST
TOWN OF MAIDEN SEWER MAP OF
PRIVATE SEWER LINE SPILL AREA
BEHIND 717 E. MAIN ST.
NOTE: MANHOLES THE SAM
7T
PRIVA]E LINE &
. SPALAREA
717 E. MAIN ST
m
N.
w E
s S
Legend. Feet
PRIVATE SEWER LINE LOCATION ESTIMATED 0 20 40 80 120 160 200 240
ALL INFORMATION RELEVANT TO THE EVENT SHOW THAT THE
PRIVATE MANHOLE LOCATION ESTIMATED CLOG AND SPILL OCCURRED WITHIN THE PRIVATE SEWER. LINE
TOWN OF MAIDEN MANHOLE AND IS BELIEVED TO BE CAUSED BY POOR. MAINTENANCE ON
TOWN OF MAIDEN SEWER LINE THE PROPERTY OWNERS PART CURRENTLY THE
jL FIRE HYDRANT COLLECTIONS, WASTE WATER TREATMENT AND
PLANNING/CODE ENFORCEMENT DEPARTMENTS ARE WORKING
TOWN OF MAIDEN WATER LINE WITH THE BUSINESSES AND PROPERTY OWNER TO
ROAD PERMANENTLY SOLVE THE CAUSE OF THE PROBLEM. TOTAL
STRUCTURES ESTIMATED SPILL VOLUME IS 50 GALLONS WITH AN ESTIMATED
15 GALLONS REACHING THE CREEK TRIBUTARY
PRODUCED BY: TOWN OF MAIDEN PLANNING DEPARTMENT, [phone] 5/4/2009
DATA: TOWN OF MAIDEN GIS AND CATAWBA CO. GIS

4*4
nop_

r Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#
Incident Number from BIMS
Incident Reviewed (Date):
Incident Action Taken: BPJ
NOV-2007-DV
......................................................................... 1
Spill Date �` Time am/ pm
Reported Date "[ / 4 Time `/ am/ pm
Reported To SWP Staff orrvStaff
Reported By 1Mct S
Phone 00Aa)zL
Address of Spill ' ,�$�'L%l��t� �t _
County Cit
Y_
Cause of Spill
Total Estimated Gallons( Est. Gal to Stream
Stream Fish Kill.- Yes No Number
Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad
PC), (b 'L', 0 t2"
v
lt�`rrn L _
.P-4 ee(' 6oaV doa)4)
v
(,�efU q� / g

Collection System
This form shall be submitted to the appropriate DWQ Regional Office within five da-ys c
overflow (SSO).
Form CS-CCO
Reporting Form
Permit Number: (-.5 00 1 Z. v (WQCS# if active, overwise use WQCSD#) S EP 19 2008
Facility: P101:' mil Incident # C) cl
Owner: fi+J n ' � r2a ; elefl Region: City: Me • An CountyDYV'AI
W���,,�,,„ree_
Source of SSO (check applicable): esanitmy Sewer Pump Station/Lift Station
SPECIFIC location ofthe SSO (be consistent in description from past reports or documentation — i.e. Pump Stationnn6, Manhole at
Westall &Bragg Street, etc.):floin flok AC ro�5 cree
Manhole#
Latitude (degrees/minute/second): Longitude (degrees/mmf u /second):
Incident Started Dt: 01 / S Time: . 3D pol Incident End Dt: GI N S/ Time: 9 :.15—
(mm-dd-yyyy) hh:mm AM/PM (mm-dd-yyyy) hh:mm AM/PM
Estimated volume ofthe SSO: v4(62 li S gallons Estimated Duration (Round to nearest hour):
Describe how the volume was determined:y .' e 64 f , �J
Weather conditions during SSO event: 514 '0 5 - e- i e A r
Did SSO reach surface waters? l 1d Y es ❑ No QUnkno n Volume reaching surface waters (gallons): ,
Surface water name: 5how dU 1'c%n f-)-% C re f, k
Did the SSO result in a fish kill? [] Yes �No [jUnknown If Yes, what is the estimated # of fish killed?
SPECIFIC cause(s) of the SSO:
❑ Severe Natural Condition ❑ Grease
❑ Inflow & Infiltration ❑ Pump Station Equipment Failure
ri Vandalism bebris in tine
❑ Pipe Failure (Break)
24-hour verbal notification (name of person contacted)
J -1'00 Ax 0 V3
❑ DWQ ¢(Emergency Mgmt. bate (mm-dd-yyyy):
❑ Roots
❑ Power outage
ti Other (Please explain in Part 11)
3 Time (hh:mm WPM):
If an S$O is ongoing, please notify the Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of fimt knowledge to all print and electronic news media providing general coverage in the
county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface waters, a public notice shall be
published within tO days and proof of publication shall be provided to the Division within 30 days. Refer to the referenced statute forfurther
detail.
The Director, division of Water Quality may take enforcement action for SSOs that are required to be reported to Division unless it is
demonstrated that.
1) the discharge was caused by severe natural conditions and there were no feasible altematives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee and/or
owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part It must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
CS-SSO Form Page I

Power Outage (Documentation of testing_ records etc should be provided of alternative ower source upon request.)
What is your alternate power or pumping source?
Did it function properly?
Describe:
When was the alternate power or pumping source last tested under load?
❑ Yes [] No [] 1VA n NE
If caused by a weather event, how much advance warning did you have and what actions were taken to prepare for the event?
Comments:
Vandalism
Provide police report number:
Was the site secured?
If Yes, how?
Have there been previous problems with vandalism at the SSO location?
If Yes, explain:
[D Yes ❑No[]NA❑NE
[i Yes [] No F1 NA [] NE
What security measures have been put in place to prevent similar occurrences in the future? © Yes ❑ No [] NA [] NE
Comments:
Debris in line (Rocks, sticks, rags and other items not allowed in the collection system etc.)
What type of debris has been found in the line?
_ RG)c k S 4- s4.'r
Suspected cause or source of debris.
©ss.1 I&, k.Jc
CS-SSO Form
Page 6

Are manholes in the area secure and intact? © Yes [] No [] NA n NE
When was the area last checked/cleaned? 0 i5
Have cleaning and inspections ever been increased at this location due to previous problems
with debris? ❑ Yes (�/No n NA [] NE
Explain:
Are appropriate educational materials being developed and distributed to prevent future
similar occurrences? Yes [] No 0 NA [] NE
Comments:
Other (Pictures and police report, as applicable must be available upon request.)
Describe:
Were adequate equipment and resources available to fix the problem?
If Yes, explain:
could not be
Comments:
Pipe Failure (Break)
Pipe size (inches)
What is the pipe material?
Yes [] No O NA [] NE
RIE/ &J Vj S aj r l 1 ham tdC, s ri edeI
repaired, what actions were taken to lessen the impact of the SSO?
What is the approximate age of line/pipe? (years old)
Is this a gravity line?
Is this a force main line?
Is the line a "Ifigh .Priority" line?
1 e free on
1 Yes[]NoF1NAONE
[] Yes ONo[INAONE
❑ Yes [/No [] NA [] NE
CS-SSO Form Page 7

Last inspection date and findings
t
If a force main then,
Was the break on the force main vertical?
Was the break on the force main horizontal?
Was the leak at the joint due to gasket failure?
Was the Ieak at the joint due to split bell?
When was the last inspection or test of the nearest air-relase valve to determine if operable?
When was the last maintenance ofthe air release performed?
If gravity sewer then,
Does the line receive flow from a force main immediately upstream of the failed
Section ofpipe?
If yes, what measures are taken to control the hydrogen sulfide production?
When was the Iine last inspected or videoed?
If line collapsed, what is the condition of the line up and down stream of the failure?
What type of repair was made?
Is the repair temporary or permanent?
Iftemporary, when is the permanent repair planned?
❑Yes❑No❑NA❑NE
❑YesQNoONAQNE
❑Yes❑No❑NA❑NE
❑Yes❑NoONA❑NE
[:] Yes [] No [l NA [t NE
Have there been other failures of this line in the past five years? []. Yes No ❑ NA E]NE
If so, then describe
System Vshatiun
ORC
Yes
CS-SSO Form Page 8

Baftp
y Y
Name: D-'1
Cert# °
Date visited: I / �I
Time visited: : � p
How wass the SSO remediated (i.e. Stopped and Gleaned up)?
[] Yes
As a representative for the responsible party, I certify that *e information contained in this report is true and accurate to the best of
my knowledge.
Person submitting claim: (-�Mv tA ee
Signature: Q",= —&,.
Telephone Number;
Date: Ci / I6 /O V
Title: SY p& - ✓ a 50 !'
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five 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).
CS-SSO Form Page 9

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# C D 1�,0
Incident Number from BIMS `r M
Incident Reviewed (Date):
Incident Action Taken: O' BPJ
NOV-2008-DV
to e e a e e e e e e e e e e e e e e e e e man e e e e e e■■■• e e e e e e e■■•■ e e a e e e e e e e e e s e e e t e e e e e e e■
Spill Date $1 a� Y� Time /L a pm
Reported Date g 0 Time o2 % am/�
Reported To SWP Staff. or EM Staff
Reported By a riyyi LU-)
Phone
,�c )C�
Pc nc�
Address of Spill
County ��,ir�t wU -city—
Cause-of Spill 1 Oc ay_
Total Estimated Gallons 3Oc Est. Gal to.Stream
Stream �T> Cece�t `'ash Kill: Yes No Number- Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

Collection System
This form shall be submitted to the appropriate DWQ Regional Office within five days c
overflow (SSO).
Permit Number: G S 1a 0 (WQCS# if active, overwise use WQCSD#)
Form CS-CCO
Sewer Overflow Reporting Form
S E P - 3 2008
Facility: 1 T 1 0 A eN Incident #
Owner: `
Region: 1A'(Y)D
KAMM
City: County:
Source of SSO (check applicable): alsanitary Sewer ❑ Pump Station/Lift Station
SPECIFIC location ofthe SSO (be consistent in description from past reports or documentation — i.e. Pump Station 6, Manhole at
Westall & Bragg Street, etc.):
Manhole#
Latitude (degrees/minu
te
/second): pLongitude (degrees/mm' u a/sec nd):
Incident Started Dt• iS r '7 ° j � m
� Time: � , .�� 1 l Incident End Dt: � Time: ,
(mm-dd-yyyy)
hh:mm AM/PM
Estimated volume ofthe SSO: 3 00 �— gallons
Describe how the volume was determined:
(mm-dd-yyyy) . hh:mm AM/PM J
timated Duration (Round to nearest hour):
Weather conditions during SSO event:. 6k n r1y1
�—
Did SSO reach surface
waters? Yes ❑ No ❑Unknown Volume reaching surface waters (gallons):
Surface water name: - C .
Did the SSO result in a fish kill? ❑ Yes ❑ No nknown If Yes, what is the estimated # of fish killed?
SPECIFIC cause(s) of the SSO:
❑ Severe Natural Condition ❑ Grease
❑ Inflow & Infiltration ❑ DWnp Station Equipment Failure
❑ Vandalism rtebris in line
❑ Pipe Failure (Break)
24-hour verbal notification (name of person contacted)
TOO
❑ DWQ vfmergency Mgmt. Date (mm-dd-yyyy): -7 : 3 ® it'''1 Time (hh:mm AM/PM):
❑ Roots -
❑ Power outage
❑ Other (Please explain in Part 11)
If an S80 is ongoing, please notify the Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shalt issue a press release within 48-hours of first knowledge to all print and electronic news media providing general coverage in the
county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface waters, a public notice shall be
published within 10 days and proof of publication shall be provided to the Division within 30 days. Refer to the referenced statute forfurther
detail.
The Director Division of Water Quality may take enforcement action for SSOs that are required to be reported to Division. unless It is
demonstrated that.
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee and/or
owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part It must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
CS-SSO Form Page I

Power outage (Documentation of testing, records etc., should be provided of alternative power source upon request.)
What is your alternate power or pumping source?
Did it function properly?
Describe:
When was the alternate power or pumping source Iast tested under load?
❑ Yes [] No [] NA [] NE
If caused by a weather event, how much advance warning did you have and what actions were taken to prepare for the event?
Comments:
Vandalism
Provide police report number:
Was the site secured?
If Yes, how?
Have there been previous problems with vandalism at the SSO Iocation?
If Yes, explain:
❑ Yes ONo[]NA[]NE
❑ Yes [j No [] NA Q NE
What security measures have been put in place to prevent similar occurrences in the future? 0 Yes ❑ No [] NA M NE
Comments:
Debris in. fine (Rocks, sticks, rags and other items not allowed in the collection system etc,)
What type of debris has been found in the line?
.R G, rn C-I - _<�;P_ r .S
or source
CS-SSO Form
Page 6

Are manholes -in the area secure and intact? dYes © No Q NA Ef NE
' 3
Ir�loez
0
When was the area last checked/cleaned?
Have cleaning and inspections ever been increased at this location due to previous problems
with debris? [] Yes ' No [] NA [] NE
Explain:
Are appropriate educational materials being developed and distributed to prevent future
similar occurrences? [/Yes 0 No [} NA 0 NE
Comments:
Mot /Wfe S
+�fber (Pictures and twlice report as applicable must be available upon reclues�
Describe:
Were adequate equipment and resources available to fix the problem? O/Yes [ No [ NA ❑ NE
If Yes, explain: _
If the problem could not be immediately repaired, what actions were taken to lessen the impact of the SSO?
Pipe Failure Mreak)
Ripe size (inches)
What is the pipe material?
What is the approximate age of line/pipe? (years old)
Is this a gravity line?
Is this a force main line?
Is the line a "High Priority" line?
[v] Yes [] No 0 NA [] NE
ElYes G No Q NA []NE
❑ Yes [�No ❑ NA [] NE
CS-SSO Form Page 7

Last inspection date and findings
If a force main then,
Was the break on the force main vertical?
Was the break on the force main horizontal?
Was the leak at the joint due to gasket failure?
Was the leak at the joint due to split bell?
When was the last inspection or test of the nearest air-relase valve to determine if operable?
When was the Iast maintenance ofthe air release performed?
If gravity sewer then,
Does the line receive flow from a force main immediately upstream of the failed
Section ofpipe?
If yes, what measures are taken to control the hydrogen sulfide production?
When was the line Iast inspected or videoed?
If line collapsed, what is the condition of the line up and down stream of the failure?
What type of repair was made?
Is the repair temporary or permanent?
Iftemporary, when is the permanent repair planned?
❑ Yes [] No ❑ NA [] NE
C] Yes [] No [] NA Q NE
❑ Yes C] No ❑ NA [] NE
❑ Yes ❑ No O NA O NE
0 Yes C] No [Q NA 0 NE
Have there been other failures ofthis line in the past five years? ❑ Yes [] No [] NA [] NE
If so, then describe
System VIAtation
w
ORC /Yes
CS-SSO Form page 8

Bdckup • [] Yes
Name: �/ ^'1(2Pl Ce
Cert# V
Date visited:
Time visited:
How was the SSO remediated (i.e. Stopped and cleaned up)?
Seer de�. Piieer fr-E4C i e �- ��� de`�'��`S 9� rd���, Gt��� r��4 �D I
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: Date:
Signature:
Telephone Number:
Title: St✓f rt) � S o F
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five 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).
CS-SSO Form Page 9

F R O M :
- TOWN of MAIDEN
113 West Main St. — P.O. Box 125
eea MAIDEN, NORTH CAROLINA 28650