WQCS00046_Regional Office Historical File Pre 2018 (3)

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MICHAEL S. REGAN
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CERTIFIED MAIL #: 7019 1120 0000 8362 0574
RETURN RECEIPT REQUESTED
January 14, 2021
Adrian T Miller
City of Belmont
PO Box 431
Belmont, NC 28012-0431
SUBJECT: NOTICE OF VIOLATION
Tracking Number: NOV-2021-DV-0019
Sanitary Sewer Overflows - November 2020
Collection System Permit No. WQCS00046
Belmont Collection System
Gaston County
Dear Mrs. Miller:
The self -reported Sanitary Sewer Overflow (SSO) 5-Day Report submitted by City of Belmont 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:
Incident Start Duration
Number Date (Mins) Location
Cause
Total Vol
Total Surface
Vol Water
(Gals) (Gals) DWR Action
202003152 11/12/2020 240 109 Point Crossing Ct Severe Natural
Condition
7,200 7,200 Notice of Violation
Severe Natural Condition
202003156 11/12/2020 240 2099 oaks parkway Severe Natural 7,200 7,200 Notice of Violation
Condition Severe Natural Condition
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Incident
Number
Start Duration
Date (Mins) Location
Cause
Total
Vol
(Gals)
Total Vol
Surface
Water
(Gals) DWR Action
202003157 11/12/2020 270 773 Cason
Severe Natural 8,100 8,100 Notice of Violation
Condition
Severe Natural Condition.
Remedial actions, if not already implemented, should be taken to correct the above noncompliance.
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 michael.meilinger(ancdenr.gov or
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U.S ,Postal Service'
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Postage
CITY OF BELMONT
9
PO BOX 431
BELMONT NC 28012-0431
ATTN: ADRIAN MILLER
dwr/mrn 1/14/21
PS Form 3800, April 2015 PSN 7530-02-00 -9047
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Signed by:
C681 AF27425.--
!singer, Regional Supervisor
ty Regional Operations Section
Regional Office
Later Resources, NCDEQ

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary .
S. DANIEL SMITH
Director
NORTH CAROLINA
Environmental Quality
CERTIFIED MAIL #: 7018 0360 0002 2099 6838
RETURN RECEIPT REQUESTED
June 25, 2020
Adrian T Miller
City of Belmont
PO Box 431
Belmont, NC 28012
SUBJECT: NOTICE OF VIOLATION
Tracking Number: NOV-2020-DV-0288
Sanitary Sewer Overflows - May 2020
Collection System Permit No. WQCS00046
Belmont Collection System
Gaston County
Dear Mr. Miller:
The self -reported Sanitary Sewer Overflow (SSO) 5-Day Report submitted by City of Belmont 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:
Incident Start Duration
Number Date (Mins) Location
202001550 5/22/2020 70 773 Cason Street
Cause
Severe Natural
Condition
Total Vol
Total Surface
Vol Water
(Gals) (Gals) DWR Action
3,150
3,150 Notice of Violation
Severe Natural Condition
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Remedial actions, if riot already implemented, should be taken to correct the'above noncompliance.
a written response to this Notice of Violation. Your response is to be received by the regional office
business days following receipt of this violation. Please include any additional documentation about t
in the response. The submittal will be considered in determining whether the Division will assess a
the cited violations.
If you have any questions, please do not hesitate to contact Michael Meilinger or me with the Water
in the Mooresville Regional Office at 704-66311699 or via email at michael.rneilinger©ncdenr.gov or
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PS Form 3800, Apri12015 PSN 7530-�0�5'
CITY OF BELMONT
pOBOX431
BELMONT NC 28012
N: ADRIAN MILLER
ATT4f22�2020 er for Instructions c__tr I �.,:a:�n.Df4,a,_ n r -:c; .,5 _plc
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y Basinger, Regional Supervisor
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Please submit
within 60
his incident(s)
civil penalty for
Quality Section
--------------

December 23, 2019
RECEIVEDINCDEN RIDW R
DEC ?7 2919
WQROS
MOORESVILLE REGIONAL OFFICE:::
Certified Mail Receipt # 7099 3400 0011 1305 6618
15 N. MAIN STREET
POST OFFICE BOX 431.
BELMONT . N.C. 28012:
PHONE [phone]
North Carolina Division of Water Quality
610 East -Center Avenue, Suite 301
Mooresville, North Carolina 28115
Attn: W. Corey Basinger =Regional Supervisor Water Quality Regional Operations Section.
Ref: Notice of Violation -- Tracking No. NOV-2019-DV-045
3
City of Belmont - WQCS00046
Dear Mr. Basinger:
The City of Belmont is in receipt of the above NOV's and as required by your letter, our
response to this: violation is as follows:
Incident # 201901781- This overflow incident, located at a Manhole near 1 Miller Street, was the
result of rags and other debris found in the line. The City determined :that the rags and other
debris was introduced:: into the line by NC Filtration; a manufacturing company. City crews
responded to reports of the overflows and immediately, the crews cleared the line of all of the
debris andrags, via the use of :our vacuum truck.: Lime was applied to the area around the
manhole after incident.
On behalf of the City of Belmont, our crews responded to the overflow as soon as the incident -
was reported and began: the process of removing the obstruction. : Once the repair was
completed, our crews cleaned the area and.lime was applied.. to the affected area. The POTW...
also, investigated the •cause of the overflow and found that.NC Filtration was not maintaining .a
private bar: screen, from their effluent, into our sanitary sewer We met with the owner and
issued a Civil Citation,: along with a follow-up letter detailing the necessary steps to prevent
future. overflows. (Please: see supporting documentation attached.)
Incident # 201901790- This overflow . incident, located : at the manhole near ::207 Crossing
Avenue, was :caused by a .buildup of grease . in the:sewer main. Citycrews responded to this
overflow immediately. The crews utilized our Jet Vac truck to remove and vacuum the :grease
from the sewer main. Once the obstruction of grease was removed, the crew applied lime to the
spill: area around :the manhole.
On behalf of the. City of Belmont, educational material on "FOG" is distributed to all of our
customers twice :a year,:: via bill inserts After this incident our staff distributed, by hand,
educational material in the immediate area of this overflow.

i
City of Belmont
November 22, 2019
NC Filtration Corporation
1 Miller Street
Belmont, NC 28012
RECEIVED f it CDENR IDW R
DEC 27 519
WQROS
MOORESVILLE REGIONAL OFFICE
115 N. Main St.
P. O. Box 431
Belmont, NC 28012
[phone]
Fax: [phone]
Dear Mr. Roman,
Enclosed you will find a "Civil Citation for Notice of Code Violation". You are receiving this because
your establishment violated the City of Belmont's Sewer Use Ordinance (SUO) by not maintaining necessary
equipment which led to a Sanitary Sewer Overflow (SSO). There is no fine associated with this Civil Citation.
Please note that if this issue is not resolved, the City of Belmont can fine up to 25,000 per day per violation as
outline in the City of Belmont's SUO and Emergency Response Plan (ERP).
On November 22, 2019,.Tanya Setzer (Wastewater Treatment Plant ORC) and I visited your
establishment due to the SSO that was reported to us from Danny Whisnant (Public Works Superintendent)
and Chuck Flowers (Utilities Director). During our visit, we talked to you about the City of Belmont's SUO
and why this is a violation of City ordinance. During this visit, I left a copy of pertinent information relating
to the City of Belmont's Pretreatment Program and Fats, Oils and Grease (FOG) Program. Should you need a
copy of this information, please contact our office and I will gladly send another copy.
On the aforementioned visit, Tanya and I discussed the following with Mr. Roman that would need to
be implemented immediately. The following items need attention:
1). Bar -Screen Maintenance: The Bar -Screen that is connected to the main sewer discharge will need to be
raised to allow settling of solids and allow adequate flow of water through the sewer.
2). Bar -Screen Documentation: Since there are multiple shifts of production, it should be documented when
someone checks on the Bar -Screen and/or services the equipment. Please note — City staff recommended that
the Bar -Screen should be checked and serviced numerous times per shift to prevent another SSO.
3). Update Policy and Procedures: Make sure staff is aware of what can and cannot be disposed of via the
sanitary sewer line (i.e — what not to flush documentation).
Thank you for your cooperation in this matter. If you have any questions, please feel free to contact
Tanya Setzer or myself at [phone]. Have a great day!
47'
Daniel Perry, MACC
City of Belmont
Pretreatment Analyst
/ /1-1. h CC
Cc: Tanya, Danny, Chuck, Adrian, File

FILL
CERTIFIED MAIL #: 7016 1370-0000 2592 0225
RETURN RECEIPT REQUESTED
December 16, 2019
Adrian T Miller
City of Belmont
PO Box 431
Belmont, NC 28012
SUBJECT: NOTICE OF VIOLATION
Tracking Number: NOV-2019-DV-0453
Sanitary Sewer Overflows - November 2019
Collection System Permit No. WQCS00046
Belmont Collection System
Gaston County
Dear Mr. Miller:
The self -reported Sanitary Sewer Overflow (SSO) 5-Day Report submitted by City of Belmont 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 incidents) cited in the subject report include the following:
Incident Start Duration
Number Date (Mins) Location
Cause
Total Vol
Total Surface
Vol Water
(Gals) (Gals) DWR Action
201901781 11/18/2019 250 Behind 1 Miller St. Debris in line
2,000 2,000 Notice of Violation
201901790 11/20/2019 94, 207 Crossing Ave Grease 752 752 Notice of Violation

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# 00o
Lite
Incident Number from BIMS 2019 0 1 110
Incident Reviewed (Date):
Spill Date
Reported Date
12c) ` lot
Time
Time
1,1 IS
Regional DWR Staff reported to or EM Staff
am/�m
A- P,vr ie
Reported by DANNL( W t4 c t v cVr
Address of Spill ?-0.7 Crto�sr, 4ve
6 s72)1J City ?2\r wriT
County
Phone
(1U-I
R (92(5
Cause of Spill
Total Estimated Gallons 752- Est. Gal to Stream 752
ckesv., Sf I4
Stream Cstr-fi` s rp4�Stream Classification
Fish Kill: Yes Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone
Manhole # Duration of SSO
1) MRO-PWS: lint�eulc or Mark Hahn
PWS Em. Cell Phone [phone]
2) DHHS:
Alexander County — Keith
All other Counties
** If you are unable to
Call the 24/7 On Call Number: 1-888-820-0520
t\\SO
verbal contact date/time
contact date/time
(828-450-5842)
(919-703-6452)
eith or Aaron,
\to
gzs P
contact date/time
contact date/time
contact date/time
Optional DHHS contact (consult with Corey/Andrew before contacting:
Valerie Lott [phone] contact date/time
Brian Combs [phone] contact date/time

".n N
Permit #
WQCS00253
WQCS00196
WQCS00233
WQCS00001
WQCS00016
WQCS00046
WQCS00107
WQCS00089
WQCS00221
WQCS00326
WQCS00088
WQCS00017
WQCS00020
WQCS00327
WQCS00036
WQCS00040
WQCS00164
WQCS00026
WQCS00059
WQCS00044
WQCS00019
WQCS00037
WQCS00030
WQCS00149
Owner and Facility Name
Bradfield Farms Water Company CS
Carolina Water Service Cabarrus Woods CS
Carolina Water Service Hemby Acres CS
Charlotte -Mecklenburg CS
City of Albemarle CS
City of Belmont CS
City of Bessemer City CS
City of Cherryville CS
City of Claremont CS
City of Concord CS
City of Conover CS
City of Gastonia CS
City of Hickory CS
City of Kannapolis CS
City of Kings Mountain CS
City of Lincolnton CS
City of Lowell CS
City of Monroe CS
City of Mount Holly CS
City of Newton CS
City of Salisbury CS
City of Shelby CS
City of Statesville CS
East Lincoln CS
Permit #
WQCS00171
WQCS00322
WQCS00222
WQCS00341
WQCS00231
WQCS00058
WQCS00165
WQCS00342
WQCS00328
WQCS00343
WQCS00310
WQCS00120
WQCS00344
WQCS00043
WQCS00125
WQCS00153
WQCS00190
WQCS00325
WQCS00180
WQCS00135
WQCS00258
WQCS00345
WQCS00054
WQCS00009
Owner and Facility Name
Greater Badin CS
Aqua Country Woods East CS
Town of Boiling Springs CS
Town of China Grove CS
Town of Cleveland CS
Town of Cramerton CS
Town of Dallas CS
Town of E. Spencer CS
Town of Harrisburg CS
Town of Landis CS
Town of Longview CS
Town of Maiden CS
Town of Marshville CS
Town of Mooresville CS
Town of Mt Pleasant CS
Town of Norwood CS
Town of Oakboro CS
Town of Stanfield CS
Town of Stanley CS
Town of Taylorsville CS
Town of Troutman CS
Town of Wingate CS
Union County CS
WSA Cabarrus Co. CS
Deemed Permitted
Permit #
WQCSD0130
WQCSD0114
WQCSD0057
WQCSD0117
WQCSD0257
WQCSD0116
WQCSD0101
WQCSD0095
WQCSD0098
WQCSD0105
WQCSD0107
WQCSD0099
WQCSD0258
WQCSD0112
WQCSD0104
WQCSD0102
Owner and Facility Name
Brooks Food Group -Brooks Food Group
Charlotte Mecklenburg Schools - Misc Laterals
City of High Shoals CS
Duke Energy Marshall Steam Station
Fallston
Goose Creek Utilities Fairfield Plantation WWTP
Harborside Dev LLC-Midtown T CS
Kennerly Dev. Group LLC-Boardwalk Villas CS
Kennerly Dev. Group LLC-Kings Point CS
Kennerly Dev. Group LLC-Moon Bay Condos CS
Kennerly Dev. Group LLC-Schooner Bay CS
Kennerly Dev. Group LLC-Spinnaker Point CS
Kingstown
Lake Norman -South Point CS
Lake Norman -Villas S Harbour CS
Lake Norman -Vineyard Pt Resort CS
Permit #
WQCSD0064
WQCSD0097
WQCSD0120
WQCSD0019
WQCSD0024
WQCSD0038
WQCSD0002
WQCSD0049
Owner and Facility Name
Lincoln County CS
Martin Dev Gp-N Point & Portside CS
Martin Marietta Mallard Creek
Town of Richfield CS
Town of Grover CS
Town of McAdenville CS
Town of Ranlo CS
Town of Spencer Mountain CS

,D
Dlvlslon of Water Resources ;
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Collection System Sanitary Sewer Overflow Reporting Form
Form CS-SSO
PART I:
This form shall be submitted to the appropriate DWQ Regional Office within five business days of the first knowledge of the
sanitary sewer overflow (SSO).
Permit Number: WQCS00046 (WQCS# if active, otherwise use WQCSD#)
Facility: Belmont Collection System Incident #: 201901781
Owner: City of Belmont
City: Belmont
Source of SSO (check applicable):
County: Gaston Region: Mooresville
[r 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): Behind 1 Miller St. •
Manhole #: N/A
Latitude (Decimal Degrees): Longitude (Decimal Degrees):
Incident Started Dt: 11/18/2019 Time: 10:15 am Incident End Dt: 11/18/2019 Time: 02:25 pm
(mm-dd-yyyy) (hh:mm AM/PM) (mm-dd-yyyy) (hh:mm AM/PM)
Estimated Volume of the SSO: 2,000 gallons Estimated Duration (Round to nearest hour): 4:10 hours
Describe how the volume was determined: 8 GPM
Weather conditions during the SSO event: Raining
Did SSO reach surface waters? Yes ❑ No ❑ Unknown Volume reaching surface waters (gals): 2000
Surface water name: Fites Creek
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 Debris in line
24 hour verbal notification (name of person contacted ): Tony Parker
DWR ❑ Emergency Mgmt
0
Date (mm-dd-yyy): 11/18/2019 Time (hh:mm AM/PM): 02:45:00 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 24-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
WHETHER OR NOT PART III IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM
CS-SSO Form
Page: 1

PART II:
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 SECTONS 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 DWR REGIONAL OFFICE UNLESS IS
Debris in line
What type of debris has been found in the line?
Rubber Gloves, Raqs, Plastic
Suspected cause or source of debris.
Mill that ties into sewer main
Are manholes in the area secure and intact?
When was the area last checked/cleaned?
07/02/2019
Have cleaning and inspections ever been increased at this location due to previous
problems with debris?
Explain:
Are appropriate educational materials being developed and distributed to prevent future
similar occurrences?
Comments:
literature will be delivered to mill owner
System Visitation
ORC
17I Yes El No ❑ NA ❑ NE
❑ Yes 17I No 1=1 NA El NE
d Yes No ❑ NA ❑ NE
I( Yes
Backup ❑ Yes
Name:
Danny Whisnant
Cert#
988751
Date visited:
11/18/2019
Time visited:
2:30 PM
How was the SSO remediated (i.e. Stopped and cleaned up)?
Jetted with Vac Truck and sucked out manholes limed area
CS-SSO Form Page: 2

As,� representative for the responsible party, I certify that the information contained in this report is true and accurate to the
be of my knowledge.
Person submitting claim: Danny Ray Whisnant Date: 11/19/19 10:15 am
Signature: Title:
Telephone Number:
Any addition 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: 3

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# () Cl 0 (1L.
Incident Number from BIMS 20190 / - e1
Incident Reviewed (Date):
Spill Date C"(Mt cj
Reported Date t (/1 WOO
Time Orir
Time
Regional DWR Staff reported to or EM Staff f o
Reported by /1y tv11isrt
Address of Spill (1.; ,, cl
4
R./ k '
Phone 7'0 - ?/ z
t )ler S'•
County g a-S7 City n-t,�,,`'+
Cause of Spill
R 6 5/0„,„
Total Estimated Gallons - CY�o Est. Gal to Stream -co
Stream 7 ?�v Plies C rkstream Classification
Fish Kill: Yes (N)Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone
Manhole # Duration of SSO
1) MRO-PWS: Clint Cook o . rk Hah . i/// verbal contact date/time
contact date/time
PWS Em. Cell Phone [phone]
2) DHHS:
Alexander County - Keith Rowland (828-450-5842) contact date/time
All other Counties - Aaron McOwen (919-703-6452) i f;6„. Abccontact date/time
** If you are unable to reach Keith or Aaron,
Call the 24/7 On Call Number: 1-888-820-0520 contact date/time
Optional DHHS contact (consult with Corey/Andrew before contacting:
Valerie Lott [phone] contact date/time
Brian Combs [phone] contact date/time

Permit #
WQCS00253
WQCS00196
WQCS00233
WQCS00001
WQCS00016
WQCS00046
WQCS00107
WQCS00089
WQCS00221
WQCS00326
WQCS00088
WQCS00017
WQCS00020
WQCS00327
WQCS00036
WQCS00040
WQCS00164
WQCS00026
WQCS00059
WQCS00044
WQCS00019
WQCS00037
WQCS00030
WQCS00149
Owner and Facility Name
Bradfield Farms Water Company CS
Carolina Water Service Cabarrus Woods CS
Carolina Water Service Hemby Acres CS
Charlotte -Mecklenburg CS
City of Albemarle CS
City of Belmont CS
City of Bessemer City CS
City of Cherryville CS
City of Claremont CS
City of Concord CS
City of Conover CS
City of Gastonia CS
City of Hickory CS
City of Kannapolis CS
City of Kings Mountain CS
City of Lincolnton CS
City of Lowell CS
City of Monroe CS
City of Mount Holly CS
City of Newton CS
City of Salisbury CS
City of Shelby CS
City of Statesville CS
East Lincoln CS
Permit #
WQCS00171
WQCS00322
WQCS00222
WQCS00341
WQCS00231
WQCS00058
WQCS00165
WQCS00342
WQCS00328
WQCS00343
WQCS00310
WQCS00120
WQCS00344
WQCS00043
WQCS00125
WQCS00153
WQCS00190
WQCS00325
WQCS00180
WQCS00135
WQCS00258
WQCS00345
WQCS00054
WQCS00009
Owner and Facility Name
Greater Badin CS
Aqua Country Woods East CS
Town of Boiling Springs CS
Town of China Grove CS
Town of Cleveland CS
Town of Cramerton CS
Town of Dallas CS
Town of E. Spencer CS
Town of Harrisburg CS
Town
Town
Town
Town
Town
Town
Town
Town
Town
Town
Town
Town
Town
of Landis CS
of Longview CS
of Maiden CS
of Marshville CS
of Mooresville CS
of Mt Pleasant CS
of Norwood CS
of Oakboro CS
of Stanfield CS
of Stanley CS
of Taylorsville CS
of Troutman CS
of Wingate CS
Union County CS
WSA Cabarrus Co. CS
Deemed Permitted
Permit #
WQCSD0130
WQCSD0114
WQCSD0057
WQCSD0117
WQCSD0257
WQCSD0116
WQCSD0101
WQCSD0095
WQCSD0098
WQCSD0105
WQCSD0107
WQCSD0099
WQCSD0258
WQCS D0112
WQCSD0104
WQCSD0102
Owner and Facility Name
Brooks Food Group -Brooks Food Group
Charlotte Mecklenburg Schools - Misc Laterals
City of High Shoals CS
Duke Energy Marshall Steam Station
Fallston
Goose Creek Utilities Fairfield Plantation WVVTP
Harborside Dev LLC-Midtown T CS
Kennerly Dev. Group LLC-Boardwalk Villas CS
Kennerly Dev. Group LLC-Kings Point CS
Kennerly Dev. Group LLC-Moon Bay Condos CS
Kennerly Dev. Group LLC-Schooner Bay CS
Kennerly Dev. Group LLC-Spinnaker Point CS
Kingstown
Lake Norman -South Point CS
Lake Norman -Villas S Harbour CS
Lake Norman -Vineyard Pt Resort CS
Permit #
WQCSD0064
WQCSD0097
WQCSD0120
WQCSD0019
WQCSD0024
WQCSD0038.
WQCSD0002
WQCSD0049
•i'I (Jl C P•
Owner and Facility Name
Lincoln County CS
Martin Dev Gp-N Point & Portsic
Martin Marietta Mallard
Creek
Town of Richfield CS
Town of Grover CS
Town of McAdenville CS
Town of Ranlo CS
Town of Spencer Mountain CS

CERTIFIED MAIL #: 7015 1520 0002 8376 2074
RETURN RECEIPT REQUESTED
Adrian T Miller
City of Belmont
PO Box 431
Belmont, NC 28012
August 22, 2019
SUBJECT: NOTICE OF VIOLATION
Tracking Number: NOV-2019-DV-0331
Sal iildi y Sewe► Overflows=-June-20-19
Collection System Permit No. WQCS00046
Belmont Collection System
Gaston County
Dear Mr. Miller:
The self -reported Sanitary Sewer Overflow (SSO) 5-Day Report submitted by City of Belmont 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:
Incident Start Duration
Number Date (Mins) Location
Cause
Total Vol
Total Surface
Vol Water
(Gals) (Gals) DWR Action
201901024 6/9/2019 147 1709 Cardinal Court Debris in line
1,816 1,816 Notice of Violation
201901038 6/9/2019 120 Morgan's Branch Lift Power Outage
Station
4,200 4,200 Notice of Violation
Flood condition

Remedial actions, if not already implemented, should be taken to correct the above noncompliance. Please submit
a written response to 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 should have any questions, please do not hesitate to contact Michael Meilinger or me in the Mooresville
Regional Office at 704-663-1699 or via email at michael.meilinger@ ncdenr.gov or corey.basingerOncdenr.gov.
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IAF27425...
singer, Regional Supervisor
y Regional Operations Section
tegional Office
later Resources, NCDEQ
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U.S.. Postal Service"'
CERTIFIED MAIL° RECEIPT
Domestic` Mail Only ',
For delivery information, visit our website at www uspscom®.
Certified Mail Fee
Extra Services & Fees (check box, add fee as appropriate)
❑ Retum Receipt (hardcopy) $
❑ Retum Receipt (electronic) $
❑ Certified Mail Restricted Delivery $
❑ Adult Signature Required $
El Adult Signature Restricted Delivery $
Postage
s
CITY OF BELMONT
PO BOX 431
BELMONT NC 28012
ATTN: ADRIAN MILLER
Dwr/mm 8/22/19
Postmark
Here
PS. Form 3800, April 2015,P.SN 7530 02•000 9047 See Reverse for Instructions

f. 9
• L
Water Resources
ENVIRONMENTAL QUALITY
January 23, 2017
Adrian T Miller, City Manager
City of Belmont
PO Box 431
Belmont, NC 28012
SUBJECT: Sanitary Sewer Overflows - December 2016
Collection System Permit No. WQCS00046
Belmont Collection System
Gaston County
Dear Mr. Miller:
ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
S. JAY ZIMMERMAN
Director
A review has been conducted of the self -reported Sanitary Sewer Overflow (SSO) 5-Day Report submitted by City
of Belmont. This review has shown the City of Belmont to be in violation of the requirements. found in the subject
permit and/or North Carolina G.S. 143-215.1(a)(1). The violations that occurred are summarized below:
Incident Start Duration
Number Date (Mins) Location
Cause
Total Vol
Total Surface
Vol Water
(Gals) (Gals) DWR Action
201602638 12/13/2016 90 300.13th St Debris in line 720 180 No Action
Remedial actions, if not already implemented, should be taken to correct the above noncompliance. Please note
that the Divsion of Water Resources (DWR) began assessing civil penalties for severe and/or repeat SSOs
starting December 1, 2007. Enforcement decisions are based on volume spilled, volume reaching surface waters,
duration, gravity, impacts to public health, fish kills and other factors.
State of North Carolina I Environmental Quality l Water Resources
610 East Center Avenue, Suite 301, Mooresville, NC 28115
704-663-1699

If you should have any questions, please do not hesitate to contact Lon Snider with the Water Quality Section in
the Mooresville Regional Office at 704-663-1699 or via email at [e-mail].
Sincerely,
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
State of North Carolina I Environmental Quality I Water Resources
610 East Center Avenue, Suite 301, Mooresville, NC 28115
704-663-1699

Water Resources •
tNYtttoNMlEtciAIL CSUALitY
CERTIFIED MAIL #: 7015 1520 0002 8386 8318
RETURN RECEIPT REQUESTED.
Adrian T Miller
City of Belmont
PO Box 431
Belmont, NC 28012
SUBJECT:
PAT McCRR.OR.'.:
DONALD R. VAN DER-VAART
S. JAY ZIMMERMAN
':Direehh7
September 22, 2016 •
NOTICE OF VIOLATION
Tracking Number: -:NOV-2016-DV-0278
Sanitary Sewer Overflows -August 2016:.
-Collection System Permit No. WQCS00046
Belmont Collection System
Gaston County
The selfreported Sanitary Sewer Overflow (SSO) 5-Day Report submitted by City of Belmont 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 outlettowaters 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:
Incident Start Duration
Number Date
(Mins) Location
Cause
Total Vol
Total • Surface
Vol. Water
(Gals) (Gals) DWR Action
201601448 8/25/2016 35 corner of Morgans Pipe Failure (Break) • 1,050. 1,050 Notice of Violation
Branch Rd. and Arctic
Trail
Remedial actions, if not already implemented, should be taken to correct the above. noncompliance.
State of North Carolina i Environmental Quality I Water Resources
610 East Center'Avenue, Suite 301, Mooresville, NC 28115
704-663-1699.

If you have any questions, please do not hesitate to contact Lon Snider with the Water Quality Section in the
Mooresville Regional Office at 704-663-1699 or via email at [e-mail].
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CERTIFIED MAIL° RECEIPT
- Domestic Mail Only
For delivery information visit our website at°www.usps com®•
EXtra Services & Fees (check (check bo�appropriate)
Return Receipt (hardcopy) $$
❑ Retum Receipt (electronic)
Certified Mall Restricted Delivery $
Adult Signature Required
Adult Signature Restricted Delivery $
Postage
Tc
s
s:
CITY OF BELMONT
PO BOX 431
BELMONT NC 28012
ATTN: ADRIAN MILLER
dwr/Is 9/23/16
PS.. Fore3800 April 2015 PSN7530-02-000.9%7'.
3asinger,.Regional Supervisor
ility Regional Operations Section
Regional Office
Water Resources, NCDEQ
lPosrtrnark '. j. -A
f/
NC'
See Reverse for Instructions
State of North Carolina I Environmental Quality 1 Water Resources
610 East Center Avenue, Suite 301, Mooresville, NC 28115
704-663-1699

Collection System: Number and Name WQCS#
Collection System SSO 24-Hour Notification
e4
077D LA
Incident Number from BIMS
Incident Reviewed (Date):
•Incident Action Taken:
BPJ
NOV-2015-DV
DV-2015- .
1100111301111111133111111131311.131311.133113311:1131113.13313112191331133111111301313r3133113191113.13131113911311311111131313131361131317111311131
Spill Date Mp° Ot CS am
Reported Date e (10 Voy(Zrijne I am_)
Reported To SWP Staff or EM Staff Jouitkia
Reported By batI4Vvy \)ikt wk Phone 0 DubctE
Address of Spill C-C) RzztAkov
City.
Cause of Spill
Total Estimated Gallons 7-- (-.) 0 Est. Gal to Stream
Stream, -Fi —e C-Ce4Gish Kill: Yes_.....NIumber Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad
County
15,'
-
IV 3 V I 5
re•

}
Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#• 0 6 O 5k4
Incident Number from BIMS
• Incident Reviewed (Date):
Incident Action Taken:
• 20150
qs
• BPJ
NOV-2015-DV
DV-2015-
44®CII6I=ma A6met a ate netts Omaart se@mH aHIdH0Htd 13mare a 0960C80Q6Bream ® elan ®$G®A CIH19A9G0tl[1
Spill Date Time am/ pm
Reported Date . Time , am/ pm
Reported To SWP Staff or EM Staff
Reported By Phone
Address of Spill
County City .
Cause of.Spitl .
Total Estimated Gallons Est. Gal to Stream
Stream Fish Kill: Yes No Number Species
Non Required Information arid other comments relating to SSO incident:
Response time minutes zone Map Quad

North Carolina Emergency Management - EM43 Reporting Page 1 of
QCS0004CQ
oi5O i9cD-LS
EM43 Reporting
EM Level:
4
Taken by:
George G Bernard
Reported by:
Danny Whisnant
County:
Gaston
Street Address:
Oak Parkway Lift Station
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
NCEM Edited:
Yes
Date/Time Reported:
12/23/2015 17:22:36
Agency:
Town of Belmont
City:
Belmont
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:
Include in Report:
Yes
Date/Time Occurred:
12/23/2015 12:45:36
Phone:
704-913-6265
Area:
13
Zip Code:
HazMat Mode:
Non-FNF Event Type:
WMD Event Type:
J
https://www.ncsparta.net/eoc7/boards/board. aspx?tableid=275 &viewid=1011 &uvid=1.44... 12/28/2015

North Carolina Emergency Management - EM43 Reporting Page 2 of 4
Event Description:
The Town of Belmont reported the release of approximately 1200 gallons of sewage from a
manhole due to heavy rain. No drinking water sources were affected and no fish kill was reported.
Cleanup operations were conducted.
Deaths: Injuries: Evacuation: Radius:
0 0 0 0
Responsible Party: Responsible Party Phone:
Point of Contact: Point of Contact Phone:
Latitude:
00.000000
RRT Request:
RRT Approved:
Longitude:
-00.000000
RRT Team Number:
RRT Mission
Number:
https://www.ncsparta.net/eoc7/boards/bo ard. aspx?tableid=275 &viewid=1011 &uvid=1.44... 12/28/2015

North Carolina Emergency Management - EM43 Reporting Page 4 of 4
NOTIFICATIONS
LEMC: SO:
PD: LFD:
CHealth: Sewer:
PWRK: Other Local Agencies:
AC: SHP/SWP:
ENV MGMT:
WATER: DRP:
CAP:
DOT: Other State Agencies:
Notes:
1725 - No notifications required - ggb
ATTACHMENTS
Filename:
Filename:
Filename:
Filename:
Filename:
Filename:
Filename:
Filename:
Filename:
https://www.ncsparta.net/eoc7/boards/board.aspx?tableid=275&viewid=1011 &avid=1.44... 12/28/2015

North Carolina Emergency Management - EM43 Reporting
Page 1 of 4
EM43 Reporting
EM Level:
4
Taken by:
Michael Bennett
Reported by:
Danny Whisnant
County:
Gaston
Street Address:
Volk St and River Drive
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
NCEM Edited:
Yes
Date/Time Reported:
12/23/2015 15:22:10
Agency:
City of Belmont
City:
Belmont
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:
Include in Report:
Yes
Date/Time Occurred:
12/23/2015 15:10:10
Phone:
704-913-6265
Area:
13
Zip Code:
28012
HazMat Mode:
Non-FNF Event Type:
WMD Event Type:
https://www.ncsparta.net/eoc7/boards/board.aspx?tableid=275&amp;viewid=1011 &amp;lab... 1/5/2016

North Carolina Emergency Management - EM43 Reporting Page 2 of 4
Event Description:
Local utility reported the ongoing sewage release from a manhole to Catawba River. At time of
report 200 gallons had been released. The river is a drinking water source, no fish kill is noted. NC
DEQ DWQ notified by NCEOC.
Deaths: Injuries: Evacuation: Radius:
0 0 .0 0
Responsible Party: Responsible Party Phone:
Point of Contact: Point of Contact Phone:
Latitude:
00.000000
RRT Request:
RRT Approved:
Longitude:
-00.000000
RRT Team Number:
RRT Mission
Number:
https://www.ncsparta.net/eoc7/boards/board.aspx?tableid=275&amp;viewid=1011 &amp;lab... 1/5/2016

North Carolina Emergency Management - EM43 Reporting Page 4 of 4
NOTIFICATIONS
LEMC: SO:
PD: LFD:
CHealth: Sewer:
PWRK: Other Local Agencies:
AC: SHP/SWP:
ENV MGMT:
WATER: DRP:
CAP:
DOT: Other State Agencies:
NC DEQ DWQ
Notes:
ATTACHMENTS
Filename:
Filename:
Filename:
Filename:
Filename:
Filename:
Filename:
Filename:
Filename:
https://www.ncsparta.net/eoc7/boards/board.aspx?tableid=275&amp;viewid=1011 &amp;lab... 1/5/2016

DEC-30-2015 09:44 FROM:BELMONT PUBLIC WORKS 7493359 TO:97046636040 P.1/5
City of Belmont
Idol Last Catawba. St vet
Belmont, NC 28012
Phone: [phone] Fax: 7,34-825-6502
FACSIMILE TRANSMITTAL
To: Barry Love
Fax #: [phone]
From: Danny Wliisnant
Phone #: [phone]
Pages: $ including cover sheet
Date: 12/30/2015
Re:'S$Q Report

M
DEC-30-2015 09:44 FROM:BELMONT PUBLIC WORKS 7493359 TO:97046636040 P.2/5
dlv�ian of Wader Resogrces
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Collection System Sanitary Sewer Overflow Reporting Form
Form CS-SSO
PART 11
This form shall be submitted:to the appropriate DWR Regional Office within five business days of the first knowledge of the
sanitary sewer overflow (SSO).
Permit Number: WQCS00,045 (WQCS# if active, otherwise use WQCSD#)
Facility; Belmont Collectiorti System Incident #: Owner: City ofBelmont
Region: Mooresville • •
City' Belmont . County: Gaston
Source of SSO (check applicable): El 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.); intersection of Volk St and River Cr.
Manhole #: n/u
Latitude (degrees/minute/second): Longitude (degrees/minute/second):
Incident Started 0t: 12/23/20 15 Time: 03:10 pm
(mm-dd-yyyy) (hh:mm) AM/PM
Estimated volume of the SSA: 960 gallons
Incident Find Dt: 12/23/2015 Time: 04:30 pm
(mm dd yyyy) (hh:mm) AM/PM
Estimated Duration (round to nearest hour): 1.5 hour(s)
Describe how the volume was determined: 8gpm
Weather conditions during the SSO event: rain
Did the SSO reach surface waters? GA Yes 0 No ri Unknown
Volume reaching surface waters: 960 gallons
Surface water name; Catawba River
Did the SSO result in a fish kill? ❑ Yes ►1t No
If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
®Severe Natural Conditions 0 Grease
QPump Station Equipment Failure ° Power Outage
°Other (Please explain in Part II)
24-hour verbal notification (name of person contacted): m
❑ Unknown
DRoots [Inflow & Infiltration
{:Vandalism ° Debris in line ❑Pipe Failure (Break)
�kYAsafte4,
❑DWR 8S4 Emergency Management Date (mm-dd-yyy): 12123/201.5Time: (hh:mm AM/PM): 03:25 pm
Per G.S. 143-216.1C(b), the'owner or operator of any wastewater collection system shall;
In the event of a discharge of 1,000 gallons or more of untreated wastewater to the surface waters of the State, issue
a press release to all print and electronic news media that provide general coverage in the county where the
discharge occurred setting Out the details of the discharge. The press release shall be issued within 24 hours after
the owner or operator Foe determined that the discharge has reached surface waters of the State.
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 I4OT PART 11 1S COMPLETED, A SIGNATURE IS REQUIRED $ g PA Fail,
`rc; r <l / s'+re-r ewe 6S r40/ t . Wee "171
Can e Aim.; 4,74 /
Form CS-SSO
Page 1

DEC-30-2015 09:45 FROM:BELMONT PUBLIC WORKS 7493359 TO:97046E36040
I - -/5 VOA s rrc f
P.3/5
Severe Natural Condition4 Shurricane, tornado, etc.)
Describe the "severe natural condition" in detail: heavy rains
How much advance warning:did you have and what actions were taken In preparation for the event? I day
Comments:
Form CS-SSO
Page 3

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# 0 00
Incident Number from BIMS 20150 d ci 5
Incident Reviewed (Date):
Incident Action Taken: BPJ
NOV-2015-DV
DV-2015-
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 61 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 61 0 0 H 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 C 0 0 0 0 0 0 611
Spill Date
z s�
5 Time cir
pm
.Reported Date F 2s75 Time / lit °Cif. am pm
Reported To SWP Staff or EM Staff . T
Reported By PP( h .47 V�,�5 rt 1 c%t Phone 761 q/ 5 1‹.
Address of Spill it? 37 VI 4 Jk 1 s-v 1 s 7
County 6-%-ro City 50-41 ..o
Cause of Spill
L®✓..�
Total Estimated Gallons L' / 6 Est. Gal to Stream We
Stream • F, #� s Cr-, Fish Kill: Yes Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# 000 Lf
Incident Number from BIMS 20150 (9 (1/7
Incident Reviewed (Date):
Incident Action Taken: BPJ
NOV-2015-DV
DV-2015-
oeemamaaaomaaadamemmaaaadeomdaomeadoamaaaQadodmmaaemamamaaaomaaammdammmdi
Spill Date 3
p �� �- �d % � Time /©, /�
pm
Reported Date l,. V /� Time 1 :o6am pm
Reported To SWP Staff or EM Staff . (A)6 .
Reported-By—-ii-olibr- A-Xj/il-it. __ - Phone— -
Address. of Spill ,70u)e 1i 14--- 67i1-7.41®n
County
G
9-1-0 A City. (}/einlort+-
.Cause of Spill -
Total Estimated Gallons
Ver
Stream U4 C.c,`-6,//0c� fi'. Fish Kill: Yes
Est. Gal to Stream' . . 115j
Number . Species
Non Required information and other comments relating to SSO incident:
Response time • minutes Zone 'Map Quad

Permit #
WQCS00253
WQCS00196
WQCS00233
Owner and Facility Name
Bradfield Farms Water CompanyCS
Carolina Water Service CabHrriis Woods CS
Carolina Water'Service Hamby Acres CS • .
• WQCS00001 Charlotte -Mecklenburg CS
WQCS00016 City of Albemarle CS • •
WQCS00046 City of Belmont CS - •
WQCS00107 City of Bessemer City CS
WQCS00089 City of Cherryville CS•
WQCS00221 City of Claremont CS
WQCSD0326 City of Concord CS
WQCS0008B City of Conover CS
WQCS00017 City of Gastonia CS -
WQCS00020 City of Hickory CS
WQCS00327. City of Kannapolis CS
WQCS00036 'City of Kings Mountain CS
WQCS00040 ' City of Lincolnfon CS
WQCS00164 City of Lowell CS'
WQCS00026 ' City of Monroe .CS
WQCS00059 City of Mount Holly CS
WQ 'SOn044.cn of Newton CS
WQCS00019 City of Salisbury CS
WQC.S00037 ' City of Shelby CS ,
WQCS00030 - City of Statesville. CS
• WQCS00149 East Lincoln CS •
WQCS00043
WQCS00125
WQCS00153
WQCSo0190
WQCS00325
WQCS00180
WQC000135
WQCS00258
Permit # Owner and Facility Name
WQCS00171 Greater Badin CS
WQCS00322 Aqua Country Woods East CS
WQCS00222 Town of Boiling Springs CS
WQC500341 Town.Of China Grove. CS
WQCS00231 Town.of Cleveland CS .
WQCS00058 Towh of Cramertori CS '
WQCS00165. Town of Dallas CS .
WQCS00342 Town of E. Spencer CS.
WQCS00328 Town of Harrisburg CS
WQCSD0343 Town of Landis CS •
WQCS00310 Town of Longview CS
W9C300120 Town of Maiden CS
WQCS00344 Town of Marshville•CS
Town of Mooresville CS
Town of Mt Pleasant CS.
Town of Norwood CS
Town of Oakboro CS • .
Town.of Stanfield CS
Town of Stanley•CS
Town of Taylorsville CS .
Town. of Troutman CS
WQCS00345 Town of Wingate CS
WQCS00054 Union County CS .
WQCS00009 WSA Cabarrus Co. CS .
•
•
Deemed Permitted
Permit# Owner and Facility Name
WQCSD0130 Brooks Food Group -Brooks Food Group
•WQCSD0114 Charlotte Mecdentiurg•Schools - Misc Laterals
WQCSD0057 City.of: High Shoals CS
WQCSD0117 Duke Energy Marshall Steam Station
WQCSD0257 Fallston •
WQCSD0116 Goose Creek Utilities Fairfield Plantation WWTP
WQCSD010i Harborside Dev (LC -Midtown T CS
WQCSD0095 Kenneriy Dev. ,Group LLC-Boardwalk Villas, CS:
WQCSD0098 • KeiinerlyDev, Group LLC=Kings Point CS •
WQCSD0105 Kennerly,Dev. Group LLC-Moori Bay Condos CS
WQCSDD107. • Kennerly Dev: Group LLC-Schoorfer.Bay"CS' •
WQCSD0099 KenneriyDev. Group LLG-Spinnaker PointeS
. WQCSD025B
WQCSD0112.
WQCSD0104
WQCSD0102
Kingstown =......:. :,...::. .
Lake Norman-South.Point.CS
Lake Norman -Villas S• Harbour CS • •
Lake Norman -Vineyard Pt Resort CS
Permit #
WQCS00064 Lincoln County C5
.WQCSD0097 'Marlin Dev Gp-N Point & Portside.CS
.WQCSD0120 : Martin Marietta Mallard Creek
• WQCDO019 Town of Richfield CS
WQCSD0024 Town of Grover CS ••
WQCS00038 • Town of McAdenvilie CS
WQCSD0002 Town of Ranlo CS . •
.WQCSD0049 Town of,Spenc-er Mountain CS..
Owrierand Facility Name
WQCSD0252 All spills which do not have a permit
....:......,:..... number assigned .

Collection System SSO 24-Hour Notification
Collection System: Number and • NameWQCS# 006 5
Incident Number from BIMS 20150 p 21 0
Incident Reviewed (Date):
Incident Action Taken: BPJ
NOV-2015-DV
DV-2015-
Reported To SWP Staff or EM Staff
----PBy y
--Reported 0 f,�y r ,t Phone
Address of Spill �-;A`I r'� hr'� ►dlii d- I/t1 /`� .5bee+Q� ,Ve�' 6t ,;Ae,
County CMG s47,11 City. ee fal OA+
Cause of Spill t- //
Total Estimated Gallons 010 Est. Gal to Stream . a 01/
Stream Gc1.4-4 ✓La lifer Fish Kill: Yes No Number Species
®0 0 0 0 g o 9 a El a q El II o ®o g q El 0 q q q e ©El o q q g q q El VI o o g CA q 47 g o 6 a a o s o 9 q o q El q D o o q q o q q el q q q ®El I
Spill Date 1,710/i 9 Time
Reported Date �, �l'5 Time 7 �% Cf
(A16
Non Required Information and other comments relating to SSO incident:
Response time • minutes Zone Map Quad

WQCS0016.4
WQCS00026 •
• Permit #
' WQCS00253
WQCS00196
WQCS00233 Carolina Water•Service Hemby Acres CS
• WQCS00001 Charlotte -Mecklenburg CS
WQCS00016 City of Albemarle CS
WQCS00046 City of Belmont CS
WQCS00107 City of Bessemer City CS
WQCS00089
WQCS00221
Owner and Facility Name
Bradfield Farms Water Company CS
Carolina Water Service Cabarrus Woods CS
City of Cherryville CS- •
City of Claremont CS
WQCS00326 City of Concord CS
WQCS0008B City of Conover CS
WQCS00017 City. of Gastonia CS
WQCS00020 City of Hickory CS -
WQCS00327 City of Kannapolis CS
WQCS00036 'City of Kings Mountain CS
WQCS00040 • City of Lincolnfon CS
City of Lowell CS
City of Monroe CS
WQCS00059 City of Mount Holly CS
wrfs00044 City of twton CS
WQCS00019 City of SalisburyCS
WQC.S00037 • City of Shelby CS
WQCS00030 - City of Statesville CS
• WQCS00149 East Lincoln CS •
Permit #
'WQCS00171
WQCS00322
WQCS00222
• WQCS00341
W QCS00231
WQCS0005B
WQCS00165
Owner and Facility Name
Greater Badin CS •
Aqua Country Woods East CS
Town of Boiling Springs CS
Town.of China Grove. CS
Town of Cleveland CS
Town of Cramertori CS
Town of Dallas CS
WQCS00342 Town of. E. Spencer CS.
WQCS00328 Town of Harrisburg CS
WQCS00343 Town of Landis CS
WQCS00310 Town of Longview CS
WQCS00120 Town of Maiden CS
WQCS00344 Town of MarshvilleCS
WQCS00043 Town of Mooresville CS
WQCS00125 Town of Mt Pleasant CS-
WQCS00153 Town of Norwood CS
• WQ0S00190 Town of Oakboro CS • .
WQCS00325 Town of Stanfield CS
WQCS00180 Town of Stanley CS
WQCSBB#35 . Town -of Taylefsvil!c CS
WQCS00258 Town of Troutman CS
WQCS00345 Town of Wingate CS
WQCS00054 Union County CS
WQCS00009 WSA Cabarrus Co 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
WQCSD0257 Fallston
WQCSD0116 Goose Creek Utilities Fairfield Plantation WWTP
WQCSD0101 Harborside Dev LLC-Midtown T CS - • -
WQCSD0095 • Kenneriy Dev. Group LC -Boardwalk Villas. QS:
WQCSD0098 KennerlyDev, Group LLC=Kings Point CS" •
WQCSD0105 Kennerly.Dev. Group LLC-ivloon Bay Condos CS
• WQCSD0107. Kenneriy Dev: Group LLC-Schooner Bay CS`
WQCSD0099 Kennelly Dev. Group LLC-Spinnaker Point CS
WQCSD0258 Kingstown •
WQCSD0112 Lake Norman -South Point CS
WQCSD0104 Lake Norman -Villas &Harbour CS
WQCSD0102 Lake Norman -Vineyard Pt Resort CS
Permit# Owner and Facility Name
WQCSD0064 Lincoln County CS
WQCSD0097 'Martin Dev Gp-N Point & Portside CS
-WQCSD0120 Martin Marietta Mallard Creek - ''
WQCSD0019 Town of Richfield CS
WQCSD0024 Town of Grover CS -
WQCSD0038 Town of McAdenville CS
WQCSD0002 Town of Ranlo CS
.WQCSD0049 Town of Spencer Mountain CS.
WQCSD0252 A!I spills which do not have a permit
number assigned .

Collection System SS
•
24-Hour Notification
Collection System: Number and•Name WQCS# 000 1--/s
Incident Number from BIMS 20150
Incident Reviewed (Date):
Incident Action Taken:
BPJ
NOV-2015-DV
DV-2015-
. El 0 0 Et El El El 13 El El 13 M. El El El El El El El 13 El 1:1 El 3 El El Et El El El El 13 El 13 El El 13 El 13 El 13 El El 13E1013E1 CI 13 El El El [3 El El E/ 13 El 13 El El El El 13 El 13 V/ El 13 I
Spill Date )1-30 / Time
\`, 30 amt m
Reported Date /5 Tinie /6
(vA
Reported To SWP Staff or EM Staff
Reported -By -61 NV- 1:5 A-f-iri*-- - Phone
Address of Spill , 4-4 51-ree 4— cli,,-/-_64,p_ W.
County 015+-00 City ,/ittoPil-'
Cause of Spill 5 //C.
Total Estimated Gallons 1 00
Stream Cct -Fa_.(A) 0 4 1444r:fish kill: Yes
Est. Gal to Stream
Number Species
Non Required Information and other comments relating to SSO incident:
Response time • minutes . Zone 'Map Quad
Otkj ol;0( no-F froo to .wc4-1-e(boc, k a/me_

• Permit #
' WQCS00253
WQCSao196
WQCS00233
WQCS00001
WQCS00016
WQCS00046
WQCS00107
WQCS00089
WQCS00221
WQCS00326
WQCS0008B
WQCS00017
WQCS00020
WQCS00327.
WQCS00036
WQCS00040 '
WQCS00164
WQCS00026 '
WQCS00059
WQrSnOn44
Owner and Facility Name
Bradfield Farms Water CompanyCS
Carolina Water Service Cabairus Woods CS.
Carolina Water -Service HembyAcres CS
Charlotte -Mecklenburg CS
City of Albemarle CS •
City of Belmont CS -
City of Bessemer City CS
City of Cherryville CS. •
City of Claremont CS •
City of Concord CS
City of Conover CS
City of Gastonia CS
City of Hickory CS -
City of Kannapolis CS
'City of Kings Mountain CS
City of Lincolnton CS
City of Lowell CS
City of Monroe CS
City of Mount HoIIyCS
City of-Wpa-CS
WQCS00019 City of SalisburyCS
WQCS00037 ' City of Shelby CS
WQCS00030 - City of Statesville CS
WQCS00149 East Lincoln CS •
•
•
•
Permit #
WQCS00171
I./vacs 00322
WQCS00222
W QCS00341
WQCS00231
WQCS00058
Owner and Facility Name
Greater Badin CS
Aqua Country Woods East CS
Town of Boiling Springs CS -
Town.of China Grove CS
Town of Cleveland CS
Town of Cramertori CS •
WQCS00165 Town of Dallas CS .
WQCS00342 . Town of E. Spencer CS
WQCS00328 Town of Harrisburg CS
WQCS00343 Town of Landis CS
WQCS00310 Town of Longview CS
.WQCS00120 Town of Maiden CS
WQCS00344 Town of Marshville •CS
WQCS00043 Town of Mooresville. CS
WQCS00125 Town of Mt Pleasant CS
WQCS00153 *Town of Norwood CS
WQ0S00196 Town of Oakboro CS •
WQCS00325
WQCSb018o
WGCS8t}135
WQCS00258
WQCS00345
Town of Stanfield CS
Town of Stanley•CS •
Tewf-ef. Taylorsvillc CS
Town of Troutman CS
Town of Wingate CS
WQCS00054 Union County CS -
WQCS00009 WSA Cabarrus Co. 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
WQCSD0257' Fallston
WQCSD0116 Goose Creek Utilities Fairfield Plantation WWTP
WQCSD0101 Harborside Dev LLG1VIidiownT CS ••• ••-
WQCSD0095 • Kennerly Dev..Group LLC-Boardwalkyi lasQS:•
WQGSD0098 Kerinerly`Dev, Group LLC:Kings Point CS
WQCSD0105 Kennerly.Dev. Group LLC-Moon Bay Condos CS
•WQCSD0107. Kennerly Dev:'Group LLC Schoorier Bay CS•
WQCSD0099 Kennerly Dev. Group LLC-Spinnaker Point CS
WQCSD0258. Kingstown
WQCSD0112 Lake Norman -South Point CS •
WQCSD0104 Lake Norman -Villas S•Harbour CS ••
WQCSD0102 Lake Norman -Vineyard Pt Resort CS
Permit# Owrier and Facility Name
WQCSD0064 Lincoln County CS
WQCSD0097 'Marlin Dev Gp-N Point & Portside CS
WQCSD0120 Martin Marietta Mallard Creek
WQCSD0019 Town of Richfield CS
WQCSD0024 Town of Grover CS •--
WQCSD0038 • Town of McAdenville CS
WQCSD0002 Town of Ranlo CS .
.WQCSD0049 Town of..Spencer Mountain.
WQCSD0252 All spills which do not have a permit
number assigned .

ilection System SSO 24-H
ur Notific
tion
Collection System: Number and Name WQCS# 006 ¥
Incident Number from BIMS 20150 -ZOT5.
Incident Reviewed (Date):
Incident Acton Taken:
BPJ
NOV-2015-DV
DV-2015-
. riammEISIESOREISIB.E117113REIPEIEIEICEIEIETEIHEIZIETE1137EfElosEinaarsmumquecapasetarisiza.iianclantstasinsumfami
•
Spill Date 1?--/F0//5 • Tirne / I 2q /Rpm
Reported Date /-7,13///5 Time 0 en pm
Reported To SWP Staff or EM Staff U6
AddresS of Spill r: Any t,---Pi- 5101,74 V/
. 'City
County ' (7a 5--6 n
Cause. of Spill
Total Estimated Gallons :9---:7 -----•
Est. Gal to. Stream
Stream be-i- 6it ? Fish Kill: Yes Number Species
kve
Non Required Information and other comments relating to SSO incident:
Response time. • minutes Zone 'Map Quad
,
(1,,/ c r'ot tint, tv p7j1i 0-P-- er
• b

Permit #
' WQCS00253
WQCS00196
Owner and Facility Name
Bradfield Farms Water Company CS
Carolina Water Service Cabarrus Woods CS
WQCS00233 Carolina Water -Service Hemby Acres CS
WQC500001
WQCS00016
WQCS00046
WQCS00107
WQCS00089
WQC500221
WQCS00326
WQCS00088
WQCS00017
WQCSD0020
• WQCS00327.
WQCS00036
WQCS00040 '
WQCS00164
WQCS00026 '
WQCS00059
wQrS00n44
WQCS00019
WQC.S00D37 '
WQCS00030
WQCS00149
•
Charlottee-Mecklenburg CS
City of Albemarle CS
City of Belmont CS
City of Bessemer City CS'
City of Cherryvffle CS• •
City of Claremont CS
City of Concord CS
City of Conover CS
City. of Gastonia CS
City of Hickory C5 • •
City of Kannapoiis CS
'City of Kings Mountain CS
City of Lincolnton CS
City of Lowell CS'
City of Monroe CS
City of Mount Holly .CS
_City of Newton --CS
City of SalisburyCS
City of Shelby CS
• City of Statesville. CS
East Lincofn CS -
Permit #
•WQCS00171
WQC500322
WQCS00222
W QCS00341
WQCS00231
WQCS00058
WQCS00165
WQCS00342
Owner and Facility Name •
Greater Badin CS
Aqua •Country Woods East CS
Town of Boiling Springs CS
Town.o€ China Grove.CS
Town.of Cleveland CS .
Town of Cramerton CS •
Town of Dallas CS
Town of E. Spencer CS. .
WQCS00328 Town of Harrisburg CS
WQCS00343 Town of Landis CS •
WQCS00310 Town of Longview CS
WQCS00120 Town of Maiden CS
WQCS00344 Town of Marshville CS
.. WQCS00043 Town of Mooresville, CS
WQCS00125 Town of Mt Pleasant C5.
WQCS00153 Town of Norwood CS
WQCs00190 Town of 0akboro CS •
WQCS00325 Town of Stanfield CS
WQC800180 Town of StanleyCS •
WQCS90135 . Tewn of Toylorsville CS
WQCS00258 • Town, of Troutman CS
•
WQCS00345 Town of Wingate CS
WQCSD0054 Union County CS •
WQCS00009 WSA Cabarrus Co. C5
Deemed Permitted
Permit #
WQCSD0130
WQCSD0114
WQCSD0057
WQCSD0117
WQCSD0257
WQCSD0116
WQCSD0101
WQCSD0095
WQCSD0098
WQCSD0105
Owner and Facility Name
Brooks Food Group -Brooks Food•Group
Charlotte Mecklenbirrg•Schools - Misc Laterals
City.of: High Shoals CS •
Duke Energy Marshall Steam Station
Fallston ...
Goose Creek Utilities Fairfield Plantation WWl`P
Harborside Dev LLC-Midtown T CS
Kennedy Dev..Group LLC-Boardwalk Villas„CS:
Kennerly'Dev,'Group LLCK'r'n`gs Point CS sr
Kennerly.Dev. Group LLC-Moon Bay Condos CS
WQCSDDI07. • Kennedy Dev: Group LLCSchoorier.Bay CS" • •
WQCSD0099-KennerlyDev. Group LLC-Spinnaker Point CS
WQCSD0258
WQCSD0112.
WQCSD0104
WQCSD0102
Kingstown
Lake. Norman -South. Point. CS -
Lake Norman -Villas S Harbour CS •
Lake Norman -Vineyard Pt Resort CS
Permit# OWrierand Facility Name
WQCSD0064 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
WQ0$D0038 . Towr of McAdenvilie CS
WQCSD0002 Town of Ranlo. CS .
.WQCSD0049 Town of, Spencer Mountain C5 .
WQCSD0252 All spills which do not have a permit
nurnber assigned . :....

Collection System SSO 24 H our Notification
Collection System: Number and Name WQCS# 6009
Incident Number from BIMS 20150 a [CO
Incident Reviewed (Date):
Incident Acton Taken: BPJ
NOV-2015-DV
DV-2015- '
. alualraCIEI6EIRE11313.E1E11111tEaperaseraariumuctomer.leasnarantirseintaRrimEnasuramatisimeseism-em m re su 13 ea
•
•
Spill Date • I ?-1/0/0 • Time 10:93C
p
Reported Date 1V- '3/ Time WO% / pm
(4)6.Reported To SWP Staff or EM Staff
'Reported-By—
AddresS of Spill cv500 • t
County
Cause of Spill
City
5A}C
Total Estimated Gallons 1.
Stream WI" rd-rft Ott, k Fish Kill: Yes
1C1110&.`"
Est. Gal to Stream
Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone 'Map Quad

Permit #
WQCS00253
WQCS00196
WQCS00233
WQCS00001
WQCS00016
WQCS00046
WQCS00107
WQCS00089
WQCS00221
WQCS00326
WQCS00088
WQCS00017
WQCS00020
WQCS00327.
WQCS00036
WQCS00040 •
WQCS00164
WQCS00026 '
WQCS00059
tnmr�nnn44 C ty nf New(nn'CS
WQCS00019 • City of Salisbury CS •
WQC.S00037 • City of Shelby CS
W.QCSb0030 - City of Statesville. CS
• WQCS00149 East Lincoln CS •
Owner and Facility Name
Bradfield Farms Water Company CS
Carolina Water Service Cabarrus Woods CS
Carolina WaterService Hamby Acres CS
Charfotte-Mecklenburg CS
City of Albemarle CS
City of Belmont CS . •
City of Bessemer City CS
City of Cherryville CS- • •
City of Claremont CS
City of Concord CS
City of Conover CS
City of Gastonia CS •
City of Hickory C5 •
City of Kannapofis CS
'City of Kings Mountain CS
City of Lincolnton CS
City of Lowell CS'
City of Monroe C5
City of Mount Hblly. CS •
Permit # Owner and Facility Name
WQCSO0i71 Greater Badin CS •
WQCS00322 • Aqua Country Woods East CS
WQCS00222
WQCS00341
WQCS00231
WQCS00058
• WQCS00165
WQCS00342
Town of Boiling Springs CS
Town.Of China Grove. CS
Town of Cleveland CS
Tovrh of Cramertori CS •
Town cif Dallas CS .
Town of E..Spencer CS. .
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
WQCSO0190 Town of Oakboro CS •
WQCS00325 Town of Stanfield CS
WQCSbOi 80 Town of Stanley CS
WQCS001'5 . Town of Toylorsvi Ic CS
WQCS00258 Town of Troutman CS
WQCS00345 Town of Wingate CS
WQCS00054 Union County CS •
• • WQCS00009 WSA Cabarrus Co. 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
W6CSD0117 Duke Energy Marshall Steam Station
WQCSD0257 Fallston •
WQCSD0116 Goose Creek Utilities Fairfield Plantation WWTP
WQCSD0101 Harborside Dev LLC-Midtown T CS •
WQCSD0095 Kennerly Dev.. Group LLC-Boardwalk Villas QS: •
WQCSD0098 KerinerlyDeV, Group LLC=Kings Point CS' ._
WQCSD0105 Kennerly.Dev. Group LLC-Moon Bay Condos CS
• WQCSDD107. "Kennerly DeV; Group LLC=Schoorier-Bay CS
WQCSD0099 " KennerlyDev. Group LLC=Spinnaker PointCS
WQCSD0258 . Kingstown -
WQCSD0112. . Lake. Norman-South.Point. CS -
WQCSDOID4 Lake Norman -Villas S Harbour CS
WQCSD0102 Lake Norman -Vineyard Pt Resort CS
• Permit# . Owner and Facility Name
WQCS00064 Lincoln County CS
WQCSD0097 'Martin Dev Gp-N Point & Portside,.CS
.WQCSD0120.:. Marlin Marietta Mallard Creek
• WQCSD0019 Town of Richfield CS --
WQCSD0024 Town of Grover CS
WQCSD0038.. Town of McAdenville CS
WQCSD0002 Town of Ranlo CS
.WQCSD0049 Town of,Spencer Mountain CS..
WQCSD0252 Allspills which do not have a permit
number assigned .

Collection System SSO 24-H
ur Notiticati,• n
Collection System: Number and NameW'QCS# cakbloPt coo k
Incident Number from BIMS 20150107
Incident Reviewed (Date):
Incident Action Taken: BPJ
NOV-2015-DV
DV-2015-
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1110 ej 0 0 0 0 0 0 0 Q 13 E7 0 0 0 0 0 0 0 0 0,D 0 0 0 ©0 0 0 0 61 0 0 0 9 0 0 0 0 0 0 0 0 El 0 0 a 0 0 0 0 0 0 ®0 0
I(
Spill Date og(zo,,
Reported Date/,o) z�r5
Time /6 ! 9 am/6
Time / o ! zi cpm
Reported To SWP Staff or EM Staff
-Reported-By P-hon
Address of Spill 7'7 3 G ��� S-4-,-g
County
Cause of Spill /U,
Total Estimated Gallons. Leo
Stream pi --tees
C fy 73-el r✓lo
Est. Gal to Stream . 4-e�.
Fish. Kill: Yes gi2 Number .. Species
Non Required Information and other comments relating to SSO incident:
Response time
minutes
Zone
Map Quad
80_9ds.1
� S.

',DEC-31-2015 08:28 FROM:BELMONT PUBLIC WORKS 7493359
TO:97046636040 P.2/3
D'
Division of Water Resources
t0�50i637
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Collection System Sanitary Sewer Overflow Reporting form
Form CS-SSO
PART I:
This form shall be submitted to the appropriate PWR Regions! Office within five business t1Qvs. of the first knowledge of the
sanitary sewer overflow (SSO).
Permit Number: WQC$00046 (WOCS# if active. otherwise use WQCSD#)
Facility: Belmont Collection System Incident #:
Region: Mooresville City: Belmont
Source of SSO (check applicable): 0 Sanitary Sewer
►�1
Owner: City of Belmont
County: Gaston
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, eto,): Cason Lift Station
Manhole #: n/a
•
Latitude (degrees/minute/sOond): Longitude (degrees/minute/second):
Incident Started Dt: '11/09/2915 Time. 11:00 ain Incident End Dt; 11/09/2015 Time; 12:30 pin
(mm-dd-yyyy) (hh:mm) AM/PM (mm-dd-yyyy) (hh:mm) AM/PM
Estimated volume of the SSO: 480 gallons estimated Duration (round to nearest hour): 1.5 hour(s)
Describe how the volume was determined: 8gpm
Weather conditions during the SSO event: rain
Did the SSO reach surface waters? la Yes [] No 0 Unknown
Volume reaching surface waters: 480 gallons Surface water name: Fites Creek Tributary
Did the SSO result in a fish kill? 0 Yes El No Q Unknown
if Yes, what is the estimated number of fish killed?
SPECIFIC cnuso(s) of the SSC):
Severe Natural Conditions (] Grease [Roots C2Inflow & Infiltration
!:Pump Station Equipment'Failure ❑ Power outage OVandalism Debris in line ❑Pipe Failure (Break)
❑Other (Please explain In Part II)
24-hour verbal notification (dame of person contacted):
IDWR ❑Emergency Management Date (mm-dd-yyy): . Time: (hh:mm AM/PM);
•
lam/
Per G.S. 143-215.1 C(b), the; owner or operator of any wastewater collection system shall:
In the event of a discharge of 1,000 gallons or more of untreated wastewater to the surface waters of the State, issue
a press release to all print and electronic news media that provide general coverage in the county where the
discharge occurred setting Out the details of the discharge. The press release shall be issued within 24 hours after
the owner or operator has determined that the discharge has reached surface waters of the State.
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.NQT PART 11 IS CQMf LETED.A.SIGNATURE IS REQUIRED SEE PAGE 13
Norm CS-SSQ Pagc I

4 y,
DEC-31-2015 08:27 FROM:BELMONT PUBLIC WORKS 7493359 TO:97046636040 P.1/3
City of Belmont
14.01 F. isi Catawba &reel:
Belmont:, NC 280:12
Phone: 704-9o1-20173 Fax: [phone]a2
FACSIMILE TRANSMITTAL
To: Barry Love
Fax #: [phone]
From: Danny Whisnant
Phone #: [phone]
Pages: 3 includi4 cover sheet
Date: 12/31/2015
Re: SSO Report

rl 'DEC-31-2015 08:28 FROM:BELMONT PUBLIC WORKS 7493359 T0:97046636040 P.3/3
r
•
•
•
•
Severe Natural Conditions (hurricane, tornado. etc.)
Describe the "Severe natural condition" In detail: heavy rains
Mow much advance warning did you have and what actions were taken in preparation for the event? 1 day
•
Comments:
Form CS-SSO
•
•
•
•
•
•
•
•
•
•
•
•
Page 3

C:•,llection Syste , SSO 24-Hour Notiflc.: Lion
Collection System: Number and Name WQCS# v od 46
Incident Number from BIMS 201501 5
Incident Reviewed (Date):
Incident Action Taken: BPJ
NOV-2015-DV
DV-2015-
s a 0 0 el a a 0 e a v 9 a v 0 ®®0 B a G o 6 0 u a r Q 9 0 0 0 m o r,©©0 rtu ri0 0 0 G rtQ m 9 rl0 m 9 0 ®®H O 0 9 8 9 q ©09 a 9 H m!
I
Spill Date to/ViC Tirne amp •
ii/ioi l5
Reported Date ; p�//a S Time i u 1.7 a- . pm
Reported To SWP Staff or EM Staff
Reported By
Address of Spill jle,i
County C- 1- -
Cause of Spill 1444,0
720;1-
City • /144
Total Estimated Gallons 5 i`.,:o Est. Gal to Stream S-6G
Stream 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 Cabarrus Woods CS
WQCS00233 Carolina WaterService Hemby Acres CS
WQCS00001 Charlotte -Mecklenburg CS
WQCS00016 City of Albemarle CS
WQCS00046 City of Belmont CS ,
WQCS00107 City of Bessemer City CS
WQCS00089 City of Cherryville CS. •
WQCS00221 City of Claremont CS
WQCS00326 City of Concord CS
WQCS0008B City of Conover CS
WQCS00017 City. of Gastonia CS
WQCS00020 City of Hickory CS •
WQCS00327 City of Kannapolis CS
WQCS00036 'City of Kings Mountain CS
WQCS00040 ' City of Lincolnton CS
WQCS00164
WQCS00026 '
WQCS00059
WQCS00044
WQCS00019
WQCS00037
City of Lowell CS
'City of Monroe CS
City of Mount Holly .CS
City of Newton CS
City of Salisbury CS
City of Shelby CS
WQCS00030 . City of Statesville. CS
WQCS00149 East Lincoln CS
Permit #
'WQCS00171
WQCS00322
WQCS00222
WQCS00341
WQCS00231
WQCS00058
WQCS00165
WQCS00342
WQCS00328
WQCS00343
WQCS00310
WQCS00120.
WQCS00344
WQCS000.43
WQCS00125
WQCS00153
Owner and Facility Name
Greater Badin CS •
Aqua Country Woods East CS
Town of Boiling Springs CS
Town.Of China Grove. CS
Town of Cleveland CS
Town of Cramerton CS
Town df Dallas CS
Town of E. Spencer CS .
Town of Harrisburg CS
Town of Landis CS
Town of Longview CS
Town of Maiden CS
Town of Marshville•CS
Town of.Mooresville CS
Town of Mt Pleasant CS.
Town of Norwood CS
WQCS00190 Town of Oakboro CS •
WQCS00325 Town of Stanfield CS
• WQCS0018o • Town of Stanley•CS
WQCS00.135 . Town of Taylorsville CS . .
WQCS00258 • Town of Troutman CS
WQCS00345 Town of Wingate CS
• WQCS00054 Union County CS
WQCS00009 W.SA Cabarrus Co. CS .
Deemed Permitted
Permit# Owner and Facility Name
WQCSD0130 Brooks Food Group -Brooks Food Group
WQCSD0114 Charlotte Mecktenburg"Schools - Mise Laterals
WQCSD0057 City. of. High Shoals CS .
WQCSD0117 Duke Energy Marshall Steam Station
WQCSD0259 Fallston
WQCSD0116 Gopse Creek Utilities Fairfield Plantation WWTP
WQCSD0101 Harborside Dev (Lb -Midtown TCS
WQCSD0095 Kennerly Dev.. Group LLC-Boardwalk Villas. CS:
WQCSD0098 Kennerly "Dev. Group LLCKngs"Point CS
WQCSD0105 Kennerly Dev. Group LLC-Moon Bay Condos CS
WQCSD0107. Kennerly Dev;'Group LLCSchooner Bay CS'
WQCSD0099 • -Kennerly Dev. Group LLC-Spinnaker Point CS
WQCSD0258 . Kingstown
WQCSD0112 Lake Norman -South Point CS
WQCSD0104 Lake Norman -Villas S Harbour CS •
WQCSD0102 Lake Norman -Vineyard Pt Resort CS
Permit # Owner and Facility Name
WQCSD0064 Lincoln County CS
WQCSD0097 Marlin Dev Gp-N Point & Portside,CS
•WQ.CSDO120. Martin Marietta Maflard Creek
WQCSD0019 Town of Richfield CS
WQCSD0024 Town of Grover CS •
WQCSD0038. Town of McAdenville CS
WQCSD0002 Town of Ranlo CS
.WQCSD0049 Town of Spencer Mountain CS.
WQCSD0252 All spills which do not have a permit
number assigned

DEC-30-2015 09:45 FROM:BELMONT PUBLIC WORKS 7493359 TO:97046636040 P.4/5
•
ri -
•'iQivielen of Water• Rrsoidrete
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Collection System Sanitary Sower Overflow Reporting Form
Four CS-SSO
PART I: •
This form shall be submitted:to the appropriate DWR Regional Office yyithin five business days of the first knowledge of the
sanitary sewer overflow (SSO)_
Permit Number WQCS00.046 (WOCS# if active, otherwise use WQCSD#)
Facility: Belmont Collection System Incident#: Owner. City ofBelmont
Region: Mooresville City: Belmont County: Gaston
Source of SSO (check eppligable). 121 Sanitary Sewer 0 Pump Station / Lift Station
SPECIFIC location of the SSQ (be consistent in description from past reports or documentation - i.e. Pump
Station 6, Manhole at Westall & Bragg Street, etc.): intersection of Volk St and River Dr.
Manhole #: n/a
Latitude (degrees/minute/seiond): Longitude (degrees/minute/second):
Incident Started Dt: 11/09/2015 Time: 05:00 pm Incident End Dt: 11/09/2015 Time: 6:00 pm
(mm-dd-yyyy) (hh:mm) AM/PM (mm-dd-yyyy) (hh:mm) AM/PM
•
Estimated volume of the $SQ: 480 gallons Estimated Duration (round to nearest hour); 1.5 hour(S)
Describe how the volume was determined: 8gpm
Weather conditions during tile SSO event: rain
Did the SSO reach surface waters? El Yes ❑ No 0 Unknown
Volume reaching surface waters: 480 gallons Surface water name: Catawba River
Did the SSO result in a fish kill? © Yes ►�1 No ❑ Unknown
If Yes, what is the estimated•number of fish killed?
SPECIFIC cause(,) of the S60:
Severe Natural Conditions ° Grease °Roots °Inflow & Infiltration
[Pump Station Equipment Failure III Power Outage ©Vandalism ° Debris in line °Pipe Failure (Break)
C'1
❑other (Please explain In Part II)
24-hour verbal notification (rums of person contacted):
ODWR ]Emergency Management Date (mm'-dd-yyy):
Time: (hh:mm AM/PM):
Per G.S. 143-215.1C(b), the owner or operator of any wastewater collection system shall:
In the event of a discharge cif 1,000 gallons or more of untreated wastewater to the surface waters of the State, issue
a press release to all prin/ and electronic news media that provide general coverage in the county where the
discharge occurred setting out the details of the discharge. The press release shall be issued within 24 hours after
the owner or operator has determined that the discharge has reached surface waters Of the State.
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 shalt 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 NOT,PABJ I. COMPLETED, A SIGN 1!R I. a QaB D SEgPAGg_13
Farm CS-SSO Page I

DEC-30-2015 09:45 FROM:BELMONT PUBLIC WORKS 7493359 TO:97046636040
' '' / / . 01- /$ Pe k Orte of
P.5/5
Severe Natural ConditJ9rt (hurricane, tornado etc)
Describe the "severe natural .condition" in detail. heavy rains
Hew much advance warning did you have and what actions were taken in preparation for the event? 1 day
Comments:
•
•
•
Form CS-SSO
Page 3

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# 0.00 4(
Incident Number from BIMS 20150 �S
Incident Reviewed (Date):
Incident Action Taken: �BPJ
NOV-2015-DV
DV-2015-
E ID 0 ID G 61 G A ID ®9 ®ID ID 8 0 0 0 0 ID H ID ID ID B 11 ID 0 B ID Q ID ID 1312 GI 0 ID ID ID 0 ID H 0 0 B 8 0 R 19 8 ID ID 9®®ID 0 13 0 ID ID A ®ID ID ID 0 ID 0 0 g 1
Spill Date Z0/3/(S Time ) 1 0 a 0 pm
Reported Date ./0 4 i� Time / II 0 I am pm
Reported To SWP Staff r EM taff
Reported By CA.vv\c.A tJa5 ivct., Phone
Address of Spill ) D yc&.vQV 'i I
County A-CkS- D City • M
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

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# d d n L J- 4
Incident Number from BIMS - 20150 ) +2 �.
Incident Reviewed (Date):
Incident Action Taken:
,°5-- el-
BPJ
NOV-2015-DV
DV-2015-
D UT E flUO 000a©000000000©0000000eon0000000000000000a000m0000000000noao�
Spill Date io/Z 05 Time 05 am/
Reported Date / 0 / S Time / P 3 g a
-ed—T-o--SWP-Staff-cor-EM-Staff �- ©-✓—�
Reported By O skn v t/ � i1r 5 ►� q ,
Address of Spill f oTr A' -
County bras`J-L v?1 City
Cause of Spill
Phone
2°1-1--I13--&26s
lot I --
Total Estimated Gallons 3 2.0 Est. Gal to Stream 3 2 O
Stream A %y
Fish Kill: Yes
Number Species _
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#
Incident Number from BIMS 20150 b33
Incident Reviewed (Date):
Incident Action Taken: 1.7 BPJ Orf-P'
NOV-2015-DV
DV-2015-
9 El 61 0 21 El 22 9 9 8 9 8 El El El 8 9 8 14 9 61 PI 8 9 2 9 Ell 8 2 13 9 8 8 61 8 8 61 9 2 El 9 8 9 9 9 8 8 2 9 9 9 67 9 9 El 9 El 9 El E4 23 9 9 2 63 27 61 El 8 2 El 1
Spill Date 514
Reported Date V/
Time 41/1P\
Time icZ 30 . am/ pm
Reported To SWP Staff or EM Staff .
Reported By
Address of Spill
a VIP /3 PA;r13/1)64 Phone ,,
.c. Fut.k_ 6aci /Oarenxigr akheg//6/
County ,04/1\ CD City Ed vnid--
Cause of Spill . c-Ctdde,( c.i. 44 Oa& ..,_,...„
Total Estimated Gallons /5-6D Est. Gal to Stram
Stream C) Fish Kill: Yes No Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad
i) 5

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# DOO
11-6
Incident Number from BIMS 20140 17 ¥ .5
Incident Reviewed (Date): I (,)9% (i S
Incident Action Taken: i BPJ
NOV-2014-DV
DV-2014-
T31^ 14( e
000vo©000006®000000000000000000000000000000000000000000000000000000001:1001
Spill Date / i/q /1 Time 2 (if-0 am/ PO
Reported Date / 1 lo, 0 -- Time ' p -ice Onpm
Regional Water Quality/ Staff reported to or EM Staff in Raleigh
7 vs. titce ,_- Pct, YWS
SSO reported by V th7 th ��r�' t Ot-----
i
Phone 709-- ?I 245--
Address of Spill Jor
County oi„c City Be II ev
Cause of Spill Ref( C3JQ-
v
Total Estimated Gallons 3 2.(9
Est. Gal to Stream j? 2f2
Stream Fish Kill: Yes (o umber. --Specie
Non Required Information and other comments relating to SSO incident:
Response time minutes
Zone Map -Quad
e acid= fJF�r
15) 1 / S J- i , 3:
ro
4
4(0Y'
fait) 8rjtf

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# 6,200
Incident Number from BIMS /m IC o [
Incident Reviewed (Date):
Incident Action Taken: BPJ
_---- -- - - _. NOV 2013-DV
DV-2013-
Spill Date 1 42 LIf % Time 612 am/
Reported Date Time (- 30 (3, pm
Reported To SWP Staff or EM Staff
Reported By Oc i nr W /�� �C O ci P14— Phone
Address of .Spill gd,0„,/County � s 4-0 si City
p6.62"--oco► zp-, , 12JCause of S ill C-� j /'��5 r�h ! ,���s i
Total Estimated Gallons 3 6 6 Est. Gal to Stream 3�
Stream in+ CN4,'io, / t (Fish Kill: Yes No 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
WQCSD0196 Carolina Water Service Cabarrus Woods CS
WQCS00233 Carolina WalerService Hemby Acres CS
WQCS00001 Charlotte -Mecklenburg CS
WQCS00016 City of Albemarle CS
WQCS00046 City of Belmont CS
WQCS00107 City of Bessemer City CS
WQCS00089 City of Cherryville CS-
WQCSO0221 City of Claremont CS
WQCSD0326 City of Concord CS
WQCS00088 City of Conover CS
WOCS00017 City of Gastonia_CS
WQCS00020 City of Hickory CS •
WQCS00327 City of Kannapolis CS
WQCS00036 City of Kings Mountain CS
WOCS00040 City of Lincolnton CS
WQCSOD164 City of Lowell CS
WQCS00026 ' City of Monroe CS
WQCS00059 City of Mount Holly CS
WQCS00044 Cify of Newton CS
WQCS00019 City of SalisburyCS
WQCS00037 City of Shelby CS
WQCS00030 - City of Statesville CS
WQCSO0149 East Lincoln CS
Permit #
•WQCS00171
WQCS00322
WQCS00222
WQCS00341
WQCS00231
WQCS00058
WQCS00165
WQCS00342
WQCS00328
Owner and Facility Name
Greater Badin CS
Aqua Country Woods East CS
Town of Boiling Springs CS
Town of China Grove CS
Town.of Cleveland CS
Town of Cramerton CS
Town of Dallas CS
Town of E. Spencer CS
Town of Harrisburg CS
WQCS00343 Town of Landis CS
WQCS00310 Town of Longview CS
WQCS00120 Town of Maiden CS
WQCS0D344
WQCS00043
WQCS00125
WQCS00153
WQCS00190
WQCSO0325
WQC500180
WQCSo0135
WQCS00258
WQCS00345
WQCS00054
WQCS00009
Town of Marshville CS
Town of Mooresville CS
Town of Mt Pleasant CS
Town of Norwood CS
Town of Oakboro CS
Town of Stanfield CS
Town of Stanley CS
Town of Taylorsville CS
Town of Troutman CS
Town of Wingate CS
Union County CS
WSA Cabarrus Co. 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 .
WQCSDD117 Duke Energy Marshall Steam Station
WQCSD0257 Fallston
WQCSD0116 Goose Creek Utilities Fairfield Plantation WWTP
WQCSD0101 Harborside Dev LLC-Midtown T CS
WQCSD0095 Kennerly Dev..Group LLC-Boardwalk Villas CS
WQCSD0098 Kennerly Dev, Group LLC-Kings Point CS
WQCSDO1D5 Kennerly Dev. Group LLC-Moon Bay Condos CS
WQCSDD107 Kennerly Dev. Group LLC-Schooner Bay CS
WQCSD0099 Kennerly Dev. Group LLC-Spinnaker Point CS
WQCSD0258 Kingstown
WQCSD0112 Lake Norman -South Point CS
WQCSD0104 Lake Norman -Villas S Harbour CS
WQCSD0102 Lake Norman -Vineyard Pt Resort CS
Permit #
WQCSD0064
WQCSDD097
WQCSD0120
WQCSDOD19
WQCSD0D24
WOCSD0038
WOCSD0002
WQCSD0049
Owner and Facility Name
Lincoln County CS
Martin Dev Gp-N Point & Portside CS
Marlin Marietta Mallard Creek
Town of Richfield CS
Town of Grover CS
Town of McAdenville CS
Town of Ranlo CS
Town of Spencer Mountain CS
WQCSD0252 All spills which do not have a permit
number assigned

Collection System SS + 24-Hour Notification.. -
Collection System: Number and Name WQCS# © 0 0 6
Incident Number from BIMS 20140 ) 3
Incident Reviewed (Date):
Incident Action Taken: g/ BPJ
NOV-2014-DV
DV-2014-
0 0 0 LI D El 0 0 0 0 0 Q Q D Q Q la D D Q 0 Ma 0 Cl D 0 0 0 Q Q D 0 D D D H D Q D Q Q II 0 D D El E D 0 0 0 0 0 0 0 0 D Q 0 0 D D Q 0 MOBS Q 0 I
Spill Date ) •l / 1 >fi Time / I S anti
Reported Date 12/1// rt Time 3 : 3 L- am/ 0572)
Regional Water Quality Staff reported to or EMI Staff in Raleigh Pr L o v P
SSO reported by ,,,/
Phone io 1 3 —6 z
Address,of Spill . 0 !r Ay'
County City 13
Cause of Spill
A.
njf
'S/5P re` bC)11.)
t_s-kait4-$
Total Estimated Gallons 2. Li-- 0 Est. Gal to Stream 1
(v).1 51-0,
Stream A-1 �/, G r-< % Fish Kill: Yes Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# Coo 6 ce
Incident Number from BIMS 20140 %go). e-P
Incident Reviewed (Date): (ci I a
Incident Action Taken: IV BPJ
NOV-2014-DV
DV-2014-
e q LIELI 0 0 0 e 0 0 0 0 8 0 0 0 e e e ®e 0 0 0 0 0 B v 0 0 0■ ®■ a• e Cl e 0• e IN o B e e 0 ®0 0 i O• 8 p 0 e ©e ■ mMM f M 0 M M 0 1
Spill Date /c /7 Time
: Cr.....) amp 1" ';00Q/1q
Reported Date 05-- Time '%/,i &pm
Regional Water Quality Staff reported to or EM Staff in Raleigh
l �� ��
�J
SSO reported by
Phone � v _I
Address of Spill
County
Cause of Spill
lo3'( aMie eude c6th-e,
5 City geefrY/0/-
4,Lecba_e_
Total Estimated Gallons ([10
Est. Gal to Stream
Stream _ eGtif4144 &)/U__ Fish Kill: Yes No Number Species
Non Required Information and other comments relating to SSO incident:
-Response time minutes Zone - -- - - " Map Quad
11 1(E C,a00,41_ ?

2_03/6769(2s--
Address of Spill l
Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#0,90 VC"
Incident Number from BIMS 2012/0 ! ZS
Incident Reviewed (Date): f' /7/49-K Zec&4,5'affri---
Incident Action Taken: ✓ BPJ
NOV-2013-DV
DV-2013-
Spill Date 7/7 0 V Time ) 'D 0 pm
Reported Date �i' �i Time (''pm
Reported To SWP Staff or EM Staff 4'{/� . 56
k-0-11
`6t a c)-I
Reported ByA!/'7ct ,�I% Zp� „ �'� Phone
57'1?
County (�. /'�/ City yl
1
Cause of Spill
GGi
Total Estimate Gallon 9( g �%,? 6 Est. Gal to Stream q(19
/IG/ 7511
Stream -
Non Required Information and other comments re ating to SSO incident:
Response time mi ` es Zones Map Quad
-1,,_„fr of-
'I44 e9-.(j4—Q-Qj
umber Species

Collection System SSO 24=Hour Notification
Collection System: Number and Name WQCS# bet Y''
Incident Number from BIMS 201300 .3
Incident Reviewed (Date):
Incident Action Taken: BPJ
NOV-2013-DV
DV 2013-
Spill Date 54
Reported Date 6 I Ce
Time :Lk a / pm — '7:4"26 'Q 1/1/1
Time /Q ; /5' am/ pm
Reported To SWP Staff or EM Staff
Reported By cC.Ka.a-
Phone
Address of Spill 4' iC•t�V Gt'c�
County 4C(,� City 1 'rkeS
Cause of Spill
Total Estimated Gallons
LLB tiutiGLJ
465, Est. Gal to Stream g�
Stream ��i, r� toc,
'J�bJ�ev Fish Kill: Yes No Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# 060
Incident Number from BIMS
Incident Reviewed (Date):
Incident Action Taken: a/ BPJ
NOV-2008-DV
ao,13'30Z3
Ige
Spill Date
Reported Date W5/ 3
Reported To SWP Staff or EM
Reported By —Cl 11 bi
0 j (14059r1
Address ofVSpill
County
Time _ : CU (and'/ pm
Time 10 Lib am/ pm
Staff
I4C Pho
4(6 acd- F4A-
Cause of Spill --
Total Estimated Gallons
l40
City c6X�
�tllti aQR t V;!),_
Est. Gal to Stream
Stream u2d4 Fish Kill: Yes No Number Species
Non Required Information and other comments relating to SSO incident:
Response time
minutes
Zone Map Quad

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# O `tC
Incident Number from BIMS
Incident Reviewed (Date):
Incident Action Taken: BPJ
,,/ NOV-2009-DV CDO cO
Z%v
Spill Date W
Reported Date
Reported ToLSWff or EM Staff
Time am/ pm
Time arril pm
Reported By SA�sL
Phone
Address of Spill P--P/UjLQ_ reJ i�
County City AIM
Cause of Spill
Total Estimated Gallons 7-?()
Stream C'_ L,i c;J
Est. Gal to Stream '-lZ
Fish Kill: Yes No Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

Permit #
WQCS00253
WQCS00196
WQCS00233
WQCS00001
WQCS00016
WQCS00046
WQCS00107
WQCS00089
WQCS00221
WQCS00326
WQCS00088
WQCS00017
WQCS00020
WQCS00327
WQCS00036.
WQCS00040
WQCSD0164
WQCS00026
WQCS00059
WQCS00044
WQCS0001 9
WQCS00037
WQCS00030
WQCS00149
Owner and Facility Name
Bradfield Farms Water Company CS
Carolina Water Service Cabarrus Woods CS
Carolina Water Service Hemby Acres CS
Charlotte -Mecklenburg CS
City of Albemarle CS
City of Belmont CS
City of Bessemer City CS
City of Cherryville CS
City of Claremont CS
City of Concord CS
City of Conover CS
City of Gastonia CS .
City of Hickory CS
City of Karinapolis CS
City of Kings Mountain CS
City of Lincolnton CS
City of Lowell CS
City of Monroe CS
City of Mount Holly CS
City of Newton CS
City of Salisbury CS.
City of Shelby CS
City of Statesville CS
East Lincoln CS
Permit #
WQCS00171
WQCS00322
WQCS00222
WQCS00341
WQCS00231
WQCS00058
WQCS00165
WQCS00342
WQCS00328
WQCS00343
WQCS0031 0
WQCS00120
WQCS00344
WQCS00043
WQCS00125
WQCS00153
WQCS00190
WQCS00325
WQCS00180
WQCS00135
WQCS00258
WQCS0034 5
WQCS00054
WQCS00009
Owner and Facility Name
Greater Badin CS
Aqua Country Woods East CS
Town of Boiling Springs CS
Town of China Grove CS
Town of Cleveland CS
Town of Cramerton CS
Town of Dallas CS•
Town of E. Spencer CS
Town of Harrisburg CS
Town of Landis CS
Town of Longview CS
Town of Maiden CS
Town of Marshville CS
Town of Mooresville CS
Town of Mt Pleasant CS
Town of Norwood CS
Town of Oakboro CS
.Town of Stanfield CS
Town of Stanley CS
Town of Taylorsville CS
Town of Troutman CS
Town of Wingate CS
Union County CS
WSA Cabarrus Co. CS
Deemed Permitted
Permit #
WQCSD0130
WQCSD0114
WQCSD0057
WQCSD0117
WQCSD0257
WQCSD0116
WQCSD0101
WQCSD0095
WQCSD0098
WQCSDO1 05
WQCSD0107
WQCSD0099
WQCSD0258
WQCSD0112
WQCSD0104
WQCSD0102
Owner and Facility Name
Brooks Food Group -Brooks Food Group
Charlotte Mecklenburg Schools - Misc Laterals
City of High Shoals CS .
Duke Energy Marshall Steam Station
Fallston
Goose Creek Utilities Fairfield Plantation WWTP
Harborside Dev LLC-Midtown T CS
Kennerly Dev. Group LLC-Boardwalk Villas CS
Kennerly Dev. Group LLC-Kings Point CS •
Kennerly Dev. Group LLC-Moon Bay Condos CS
Kennerly Dev. Group LLC-Schooner Bay CS
Kennerly Dev. Group LLC-Spinnaker Point CS
Kingstown
Lake Norman -South Point CS
Lake Norman -Villas S Harbour CS
Lake Norman -Vineyard Pt Resort CS
Permit #
WQCSD0064
. WQCSD0097
WQCSD0120
• WQCSD0019
WQCSD0024
WQCSD0038
WQCSD0002
WQCSD0049
Owner and Facility Name
Lincoln County CS
Martin Dev Gp-N Point & Portside CS
Martin Marietta Mallard Creek
Town of Richfield CS
Town of Grover CS
Town of McAdenville CS
Town of Ranlo CS
Town of Spencer Mountain CS
WQCSD0252 All spills which do not have a permit
number assigned

4 S
Feb 06 09 11:16a Cit. i Of Belmont
7048250514
p.1
M
Form CS-SSO
CoiIectien System Sanitary Sewer Overflow Reporting Form
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
-3afL! `EiQ (WOES# if active, otherwise use WOOSD#)
Facility: _ ,b l�- u -j (;� "
Incident # �� 1
• Owner: t a-O MOp{,�
City: __BP (Mira— 104C--
Source of SSO (check applicable):
SPECIr1C location of the SSO (be
Manhole at Westall 8 Bragg Street,
tvl,e rlhole#
Region:
�r1'1 s-f o n
County:
Sanitary delver Pump Station/Lift Station
consistent in description from past reports or dOCurne Cation - ..e. Pump Station 6,
etc.) ��_. -+^ _KrTh.
Latitude (degrees/minute/second):
Incident Stared Di:
(mm-th -yyyy)
Estimated volume of tho SSO'
im:mrr AM/PM
Longitude(degrees/mi e/tecdnd)•
Time: W ?. jO et Incident End DI:
Urn-dd-yyyy)
•
Deesc.ribe how the volume was determined:
Weather conditions during SSO event
gallons Estimated Duration (Round to nearest hour).
h B 01 jai X Rp fu .5 ) Tick
O
Did SSO reach surface w
/a� aters? 1Yes NOD Ur}knewn
Surface water name .(-c0.11
Did the SSO result in a fish kilt? 0 Yes ❑ NCE) Unknown
SPECIFIC tause(s) of the SSO;
r❑ Severe Natur-.:al Condition ❑ Grease ❑ Roots
El
Inflow and Infiltration 0 Pump Station Equipment Failure 0 Power outage
Vandalism Debris in line ❑ Other (Please explain in Pad II)
Pipe Failure (Break) 7 r��
2a-hour Vorb,al notification (nacre of person conrscted) v `t C'Y1`-tt/y�ll -u
UWG J Emergency Mgmt. Date (mm-dd•yyyy)-
•
12
Volume reaching surface waters (gallons);
if Yes, what is tho estimated number of Fish killed^
Time'
l t - ,`�� Q J71.
hh;tnrrl AMJPM f_
Ili I 1 -s
5/ 0 Time (hh:mm AM/PM)'
If an SSO is ongoing, please notify Regional Office one daily basis until SSO can be slopped,
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-ho0rs of first knowledge to all print and electronic news media providing general
coverage in the count Cilt rCthe ;; scharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters..r public notice shall be published within 10 days and proof of publication shall be provided to the. Division within 30 days.
1-2efer to this r'eCerencet� statute for further defail-
Tne Director, Division of Water Cualiiy, may U?ke enforcement action for SSOS Mal are required to be reported to Division unless it
i-s offs —mac] that:
1) the discharge was caused by severer 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 rcnsonublc Control of the Permitter
and/or owner. and the discharge could not have been prevented by II-ie exerciser of reasonable control.
Pad it Must be completed to provide, a u.^-.lifitc,ton claim fcr either of the above situations. This information will be the bests
for iho determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHET! !ER OR NOT PART II IS COt,,3P1_ETEC-)• A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-53O Form
F':ace
Cfi '1C> ` ' L( 3 - Icy oLt o
1

4
Feb 06 08 11:16a Cites Of Belmont
7048250514 p.2
Grcaso (Documentation such as cleaning, inspections, enfarcement actions. past overflow reports,
uca iona ma erta an is n u ion are, el-c. s' ibuld be av,`Th`5T? upon request.)
When was the last time thiv specific line (or wet well) was cleaned?
I)o you have an enforceable grease ordinance that requires new or retrofit of grease trapsfnterceptors?
Have there been recent inspections and/or enforcement actions taken On nearby restaurants or other
nonresidential grease cont,ibutor•?
EXplain.
u:❑ No ❑ NA ❑ NE
No ❑ NA ❑ NE
Have [here been other SS0s or blockages in this area that were also Caused by grease?
Yc-r--+ No ❑ NA ❑ NE
When?
LVIU>��, ilt� `�Z�t` 6'-"� r -.L-CJ
I! yes.describe them: I j - ) a
0 L.vc) tru_.* C>,r aa2 l�-�';1.4k. ��r 4)..(
Havo cleaning and inspections ever been jr.creaeed 31 this location? LJ Yea' No ❑ NA_ NE
Expl:din.
Have educational materials about grease be--n distributed in the past?
When?
and to whom?
o�C Uwj a o�j .
-he N
Explain? lam-- l • 62GC..40.1-: lry
YcJNo❑NA❑>J
if u7ra .SS0 Qc u ed at a pump station, when was the wet well and pumps last checked for grease •
.iccr:mutation?
4v"re the floats clean?
Cer•rp rents'
•
•
•
❑yo` tvq❑NA❑NE
CS-SSD Fotin
Page 4

Feb 06 08 11:16a City Of Belmont
7048250514
p.3
System Visitation
ORC
❑ Yas
Backup
Yos
Name:
cert#
Dote visited:
Time visited'
How was the SSC) remediat d (Le. Stopped and cleaned
Z '
GCb�zct�•� GZ-'L� �, ram, ..
lice
Jf cL , _ 4 +„ter`,-P.�1t,�•
As representative far the responsible party, 1 certify that the inform; (ion contained in this report is true and accurate to •
Person submitting claim: 06
Signature;
Telephone Number:
Spy 379/
Date:
Title: �Gt/‘J-7•
Any additianal information desired to be submitted should be sent' . the at;propri;Ae Division Regionol Office within five days of first
knowledge of the SSQ with refer��rtce io the incident number (the i ctdenl nuiiuber is only generated when electronic POP of this
tom) iticorrmp:etr.:d, if used).
e ./xQ (G Lad GC/.-- , `/li4)
a_41-e. /t e -mac-L . a-zeztLLO Otx A-4 L4t...t
t;`3,S O i-orrn
Pogo :.5

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# •
Incident Number from BIMS 20140 7/
Incident Reviewed (Date):
Incident Action Taken: i/ BPJ
NOV-2014-DV
DV-2014-
�(P
ua•o111eoeME•m11oc•ooA■eMENNMNee1110MMMMMMe111oRENNESee■®MMMMMMc•o•®Mc11vm11o11ua•11
Spill Date
/0
Reported Date '406
Time am/ pm
Time LIS am/ pm
Reported To SWP Staff or EM Staff 6
Reported By 4t&V\r\Ly ea, Phone
Address of Spill
g 60 615l Casevo
Count_ City edknOd-
Cause of Spill &&u:
Total Estimated Gallons ,i f fo��
Est. Gal to Stream 700
Stream — eice.„...k Fish Kill: Yes No Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

North Carolina Emergency Management - EM43 Reporting Page 1 of 3
North Carolina Emergency Management - EM43 Reporting
Print 11 Return To List
EM Level:
4
Taken by:
Zakare Whicker
Reported by:
Danny Whisnant
County:
Gaston
Street Address:
807 Gaston Ave Extension
Type: Wastewater
Animal Disease Event Type:
Complaint Bvent Type:
FNF Event Type:
HazMat Event Type:
Homeland Security Event:
Other Event Type:
Transportation Event Type:
Weather Event Type:
State Resource Request
NCEM Edited:
Yes
Date/Time Reported:
10/05/2013 19:35:51
Agency:
City of Belmont
City:
Belmont
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:
Include in Report:
Yes
Date/Time Occurred:
10/05/2013 17:30:00
Phone:
704-913-6265
Area:
13
Zip Code:
HazMat Mode:
Non-FNF Event Type:
WMD Event Type:
Event Description:
Local utilities reported the release of 480 gallons of sewage from a manhole to an unnamed creek.
The creek is a tributary of the Catawba River. The creek is not a drinking water source, no fish kill
was reported, and cleanup operations were conducted by placing line and pumping the main line.
Filename:
Deaths:
0
Responsible Party:
Injuries:
0
Evacuation:
0
Responsible Party Phone:
Point of Contact: Point of Contact Phone:
Latitude:
00.000000
RRT Request:
RRT Approved:
Longitude:
-00.000000
RRT Team
Radius:
0
RRT Mission
https: //www.ncsparta.net/eo c7/bo ards/board. aspx?tableid=275 &viewid=1011 &uvid=1.417... 10/7/2013

North Carolina Emergency Management - EM43 Reporting Page 3 of 3
NOTIFICATIONS
LEMC: SO:
PD: LFD:
CHealth: Sewer:
PWRK: Other Local Agencies:
AC: SHP/SWP:
ENV MGMT:
WATER: DRP:
CAP:
DOT: Other State Agencies:
Notes:
ATTACHMENTS
Filename:
Filename:
Filename:
Filename:
Filename:
Filename:
Filename:
Filename:
Filename:
https://www.ncsparta.net/eo c7/boards/bo ard. aspx?tableid=275 &viewid=1011 &uvid=1.417... 10/7/2013

Collection Sy'§tem SSO 2.4-Hour Notification
Collection System: Number and Name WQCS# OW�
Incident Number from BIMS
Incident Reviewed (Date):
Incident Action Taken: / BPJ
NOV-2007-DV
Spill Date `365-1/& Time 1( &p m /d :4,4C
Reported Date 3 5/f3 Time /0 D am/ pm
Reported To SWP Staff or EM Staff
Reported By ,ba r. 0- y)a,k' Phone
Address of Spill � C.t Rd - PS , jg 4
g-ct.Tt_tpo County City 4,61Wit
Cause of Spill 9kLeCtico - /66Ii ?wJ
(� FL
Total Estimated Gallons `"C b Est. Gal to Stream
q0
Stream — Fish Kill: Yes No Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# '
Incident Number from BIMS ZE) t 3OQ Wd
Incident Reviewed (Date):
Incident Action Taken: (/ BPJ
NOV-2012-DV
i•ZJ MuL ou•m®m11111cMIEo®■NNvNN®oa11pp® a MMMMMMMttomoMMMMMMMcMeoMMM MMMMiMMe®E■
Spill Date 1N? Time 1 2.3o am/ g
Reported Date (RI( ( Time i 3 S am/ ti
Reported To Staff or EM Staff
Reported By
Address of Spill 1
County(191'0`-)
Cause of Spill C'Q-d-L...
L,
Phone
.504
City MI16,4
Total Estimated Gallons (3S' Est. Gal to Stream
Stream Lvr'�i S 3- Fish Kill: Yes No Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#
Incident Number from BIMS 2-C) 3 ©C.)
Incident Reviewed (Date):
Incident Action Taken: ✓ BPJ
NOV-201e-DV 60 / 1
io31.m11nn®cormuvMMMMMMMMMMao®oacc1111pue•aanvawNNNNNNnNeem■®■■a■®oe11eMcNIIIIIIoMn
--7) $ WS--/(r
Spill Date 17Cl (1 3Time 1 5. Ls - el Pm
Reported Date //[:(I,) Time : 3 3 am/ rn
r P
Reported To Staff or EM Staff L S
Reported By e 4 Co a 1- 4- Phone
Address of Spill r M4-(ti C Co trivef-)
County City-(r'-'-e'-`
Cause of Spill Lg,-S 614-/5)
Total Estimated Gallons 690 Est. Gal to Stream 3oo
'J � .9
Stream 70e. -c,1-, Cc— Fish Kill: Yes 6� Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad
ide Au vIgeo7L 4Z67.4

p.; Delete
SSO Details
24 Hours
24 Hour
Details
5 Dav Details Questions Agencies Events 06\
Permit
Facility Name
Owner
City
SSO Start Date/Time :
Report Received :
: WQCS00046
: Belmont Collection System
City of Belmont
01/16/2013
12:37 pm
01/16/2013
Incident Number : 201300102
County : Gaston
Region : Mooresville r
/40uk
Est. Volume :
Report Entered :
Did SSO Reach Surface Water : ( Yes r No r Unknown Vol. Reaching Surface Water :
Did SSO result in Fish Kill : r Yes r No r Unknown Estimated Fish Kill :
Water Body : Stowe Branch
5 Day Details
SSO Start Date/Time :
End Date :
01/16/2013
1480
0
Duration :
Est. Volume :
Report Received : I Report Entered :
Did SSO Reach Surface Water : r Yes r No r Unknown Vol. Reaching Surface Water :
Did SSO result in Fish Kill : r Yes r No r Unknown Estimated Fish Kill :
Water Body
Regional Contact : [Snider, Lon .
County :
* Location of the SSO :
130 Mrytle Street
Manhole# :
gallon
gallon
gallon
f gallon
Mt Date/Time (mm/dd/yyyy hh:mm am):
Comments :
Specific Cause (check all that Apply)
❑ Severe Natural Condition 0 Inflow and Infiltration ❑ Vandalism
❑ Grease ❑ Pump Station Equipment Failure t❑-iiebris in line
O Roots 0 Power outage 0 Other (Please explain in Part II) 0 Pipe Failure (Bre,
City :
(//JLd /Pl !3
btze 4u19 , Sent
/9/
76te ck4/446/2-4—

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# COO L/
Incident Number from BIMS P2-0(2.0 I VC2-
Incident Reviewed (Date):
Incident Action Taken:
BP
NOV-2012-DV C 59
imrrmrr■mmrrrmm■rrrrrr■■mmmmmmerrPmmrrmrrrrrrmmrmesmrmrmrrrrmmrrrmrrremr■
Spill Date ( f (3 Time 2-5 am/ pm
Reported Date l( (I Time (01 f2 am/ pm
Reported To SWP Staff or(taff
Reported By(Ai„, Phone
Address of Spill teD-S w
County City
Cause of Spill
Total Estimated Gallons !603
Est. Gal to Stream
60.3.
Stream Fish Kill: Yes No Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

. North Carolina Emergency Management _ EM43 Reporting Page 1 of 3
North Carolina Emergency Management - EM43 Reporting
Print
Return To. List
EM Level:
4
Taken by:
cletourneau
Reported by:
Stanly Whisnant
County:
Gaston
Street Address:
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
NCEM Edited:
Yes
Date/Time Reported:
11/10/2012 22:12:55
Agency:
Local utilities
City:
Belmont
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:
Include in Report:
Yes
Date/Time Occurred:
11/10/2012 22:12:55
Phone:
7049136265
Area:
13
Zip Code:
HazMat Mode:
Non-FNF Event Type:
WMD Event Type:
Event Description:
Local utilities reported the release of 1600 gallons of sewage due to debris in the line. All of the
product reached Abbey Creek. Clean up was conducted
Filename:
Deaths:
0
Responsible Party:
Point of Contact:
Latitude:
00.000000
RRT Request:
Injuries:
0
RRT Approved:
Evacuation:
0
Responsible Party Phone:
Point of Contact Phone:
Longitude:
-00.000000
RRT Team
Number:
Radius:
0
RRT Mission
Number:
https://www.ncsparta.net/eoc7/boards/board. aspx?tableid=275&viewid=1011 &uvid=1.3 8... 11 / 13/2012

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#
Incident Number from BIMS q V Z0 `1 :!
Incident Reviewed (Date):
Incident Action Taken:
Spill Date
Reported Date
NOV-2012-DV
Time
m
Time 5,S cam/ pm
Reported To SWP Staff or EM Staff
Reported By
L9APJ Phone
Address of Spill e-0"5 OE
County City
Cause of Spill LJ
Total Estimated Gallons`(0 Est. Gal to Stream
Stream 4'b b r Fish Kill: Yes No Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# y
Incident Number from BIMS
Incident Reviewed (Date):
Incident Action Taken:
�0laotgLty
BPJ
NOV-2012-DV
1 ❑ ■ ■ m ■ e ■ e o n o ■ o EEEEEE o ■ ■ ■ ■ ©■ ■ o o e ■ ■ p ®u a ■ c m ■ ■ ■ C ■ ®IOCIG e E ■ ■ o ■ ■ ■ ■ u ■ ■ o ■ ■ ■ u o ■ ®o m ■ m
Spill Date
Time o2 .` /Q am/
Reported Date I f / c // 2 Time 3 ; / 6 am/
Reported To SWP Staff or EM Staff f.1..e K //
Reported By a v (A/111'5 n oi Phone `2N— (J 3 — ‘071
Address of Spill © �4- 41, '%»/ ivn e r;,, //1,,,g j/ .711-, e-/—
County GA 4 }-oh City /%e-/i�nn/1
Cause of Spill
are c 5
/dlo,6‘5
/410 hed)
Total Estimated Gallons .2 00 Est. Gal to Stream C9 0
Stream
bet Creek
Fish Kill: Yes
Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# t
Incident Number from BIMS
Incident Reviewed (Date):
Incident Action Taken:
BPJ
NOV-2012-DV
1a1•aeeeuoomooe■eeueoso■eooeoaeeepoaueoeeeamEeoou222ua2o111111ae®a11e®uaeaeuo■
Spill Date / I Time am/
Reported Date ((6 Time 3 S- am/ fb
Reported To SWP Staff or EM Staff
L5
Reported By (��Sn Phone
Address of Spill I L , 1(/( jc 6eO L--c
County City
Cause of Spill vL__ I�l�13)
Total Estimated Gallons 2-1(v Est. Gal to Stream 740
Stream Fish Kill: Yes Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS.# COD qce
Incident Number from BIMS 9O/aa /4-1) (�
Incident Reviewed (Date):
Incident Action Taken: BPJ
NOV-2007-DV
Spill Date 11/7
Reported Date 5-1/(7
Time
Time
Reported To SWP Staff or EM Staff
Reported By
Address of Spill
County CtS)k
Cause of Spill
am pm
am/
h A9 &Jai5 /UG'.ct-t' Phone
Roca igoy 0(
City
- IUogtrn nUl Gee_61da,;_,X
Total Estimated Gallons
Stream Cry
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad
Est. Gal to Stream A540
Fish Kill: Yes No Number Species
Shez/fri

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# C.)L.0(-6
Incident Number from BIMS c OO 2,91
Incident Reviewed (Date):
Incident Action Taken: / BPJ ( ersrcr
NOV-2012-DV
n -A--s s�
Spill Date
Reported Date
Time 30/ pm
Time vl S 31/ pm
Reported To SWP Staff or EM Staff
Reported By
GS
VTh^'^' . (1 Phone
Address of Spill As caC' cir (.Q.s Dr
County City `dam,
Cause of Spill GQc..szP� S
Total Estimated Gallons 1r245 Est. Gal to Stream
Stream / ti669,
ish Kill: Yes
Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad
444,i_5 S/+N-V74

Collection System SSO 24-Hour Notification
Collection System: Number and N.ame WQCS# (O&--6
Incident Number from BIMS . (D'( CO CAC°
Incident Reviewed (Date):
Incident Action Taken: BPJ
NOV-2010-DV
Spill Date -Zrj. Time (2 3 ' am/ ligi
Reported Date .. Z 117 Time ( v am/ pb
Reported To Staff or EM Staff
Reported By • (- �s Phone
Address of Spill 6 (.3 " cr SJ—
'County ' City- is
Cause of Spill -41: - •
Total Estimated Gallons /00 Est.. Gal to .Stream 106
Stream
Fish Kill: Yes (N) Number • Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad.

Permit #
WQCS00253
WQCS00196
WQCS00233
WQCS00001
WQCS00016
WQCS00046
WQCS00107
WQCS00089
WQCS00221
WQCS00326
WQCS00088
WQCS00017
WQCS00020
WQCS00327
WQCS00036
WQCS00040
WQCS00164
WQCS00026
WQCS00059
WQCS00044
WQCS00019
WQCS00037
\ QCS00030
WQCS00149
Owner and Facility Name
Bradfield Farms Water Company CS
Carolina Water Service Cabarrus Woods CS
Carolina Water Service Hemby Acres CS
Charlotte -Mecklenburg CS
City of Albemarle CS
City of Belmont CS
City of Bessemer City CS
City of Cherryville CS.
City of Claremont CS
City of Concord CS
City of Conover CS.
City of Gastonia CS
City of Hickory CS
City of Kannapolis CS
City of Kings Mountain CS
City of Lincolnton CS
City of Lowell CS
City of Monroe CS
City of Mount Holly CS
City of Newton CS
City of Salisbury CS
City of Shelby CS .
City of Statesville CS
East Lincoln CS
Permit #
WQCS00171
WQCS00322
WQCS00222
WQCS00341
WQCS00231
WQCS00058
WQCS00165
WQCS00342
WQCS00328
WQCS00343
WQCS00310
WQCS00120
WQCS00344.
WQCS00043
WQCS00125
WQCS00153
WQCS00190
WQCS00325
WQCS00180
WQCS00135
WQCS00258
WQCS00345
WQCS00054
W QCS00009
Owner and Facility Name
Greater Badin CS
Aqua Country Woods East CS
Town of Boiling Springs CS
Town of China Grove CS
Town. of Cleveland CS
Town of Cramerton CS
Town of Dallas CS
Town of E. Spencer CS
Town of Harrisburg CS
Town of Landis CS
Town of Longview CS
Town ()Walden CS
Town of Marshville CS
Town of Mooresville CS
Town of Mt Pleasant CS.
Town of Norwood CS
Town of Oakboro CS •
Town of Stanfield CS
Town of Stanley CS •
Town of Taylorsville CS
Town of Troutman CS
Town of Wingate CS
Union County CS
WSA Cabarrus Co. CS
Deemed Permitted
Permit #
WQCSD0130
WQCSD0114
WQCSD0057
WQCSD0117
WQCSD0257
WQCSD0116
WQCSD0101
WQCSD0095
WQCSD0098
WQCSD0105
WQCSD0107
WQCSD0099
WQCSD0258
WQCSD0112
WQCSD0104
WQCSD0102
Owner and Facility Name
Brooks Food Group -Brooks Food Group
Charlotte Mecklenburg Schools - Misc Laterals
City of High Shoals CS .
Duke Energy Marshall Steam Station
Fallston
Goose Creek Utilities Fairfield Plantation WWTP
Harborside Dev LLC-Midtown T CS
Kennerly Dev. Group LLC-Boardwalk Villas CS
Kennerly Dev. Group LLC-Kings Point CS
Kennerly Dev. Group LLC-Moon Bay Condos CS
Kennerly Dev. Group LLC-Schooner Bay CS
Kennerly Dev. Group LLC-Spinnaker Point CS
Kingstown
Lake Norman -South Point CS
Lake Norman -Villas S Harbour CS
Lake Norman -Vineyard Pt Resort CS
Permit #
WQCSD0064
WQCSD0097
WQCSD0120
WQCSD0019
WQCSD0024
WQCSD0038
WQCSD0002
WQCSD0049
Owner and Facility Name
Lincoln County CS
Martin Dev Gp-N Point & Portside CS
Martin Marietta Mallard Creek
Town of Richfield CS
Town of Grover CS
Town of McAdenville CS
Town of Ranlo CS
Town of Spencer Mountain CS
WQCSD0252 All spills which do not have a permit
number assigned

Address of Spill
County
Cause of Spill
Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# (906
Incident Number from BIMS 00 /0/ Z5/b
Incident Reviewed (Date):
Incident Action Taken: BPJ
NOV-2008-DV
Spill Date 1 S
Reported Date c=2-L
Reported To SWP Staff or EM Staff
Time _ / . /0 am/ fir
Time • OC) am
gS
Reported By E1/�J Phone
cbck IN\ 113%Bjs QoAx4---
Cityw��
cD
Total Estimated Gallons
Stream l)
5.+0(,)c
Est. Gal to Stream �t°16
U-{.k Fish Kill: Yes No Number Species
Non Required Information and other comments relating to SSO incident:
Response time
minutes Zone Map Quad

Permit #
WQCS00253
WQCS00196
WQCS00233
WQCS00001
WQCS00016
WQCS00046
WQCS00107
WQCS00089
WQCS00221
WQCS00326
WQCS00088
WQCS00017
WQCS00020
WQCS00327
WQCS00036
WQCS00040
WQCS00164
WQCS00026
WQCS00059
WQCS00044
WQCS00019
WQCS00037
WQCS00030
WQCS00149
Owner and Facility Name
Bradfield Farms Water Company CS
Carolina Water Service Cabarrus Woods CS
Carolina Water Service Hemby Acres CS
Charlotte -Mecklenburg CS
City of Albemarle CS
City of Belmont CS
City of Bessemer City CS
City of Cherryville CS
City of Claremont CS
City of Concord CS
City of Conover CS
City of Gastonia CS
City of Hickory CS
City of Kannapolis CS
City of Kings Mountain CS
City of Lincolnton CS
City of Lowell CS
City of Monroe CS
City of Mount Holly CS
City of Newton CS
City of Salisbury CS
City of Shelby CS
City of Statesville CS
East Lincoln CS
Permit #
WQCS00171
WQCS00322
WQCS00222
WQCS00341
WQCS00231
WQC.S00058
WQCS00165
WQCS00342
WQCS00328
WQCS00343
WQCS00310
WQCS00120
WQCS00344
WQCS00043
WQCS00125
WQCS00153
WQCS00190
WQCS00325
WQCS00180
WQCS00135
WQCS00258
WQCS00345
WQCS00054
WQCS00009
Owner and Facility Name
Greater Badin CS
Aqua Country Woods East CS
Town of Boiling Springs CS
Town of China Grove CS
Town of Cleveland CS
Town of Cramerton CS
Town of Dallas CS
Town of E. Spencer CS
Town of Harrisburg CS
Town of Landis CS
Town of Longview CS
Town of Maiden CS
Town of Marshville CS
Town of Mooresville CS
Town of Mt Pleasant CS
Town of Norwood CS
Town of Oakboro CS
Town of Stanfield CS
Town of Stanley CS
Town of Taylorsville CS
Town of Troutman CS
Town of Wingate CS
Union County CS
WSA Cabarrus Co. CS
Deemed Permitted
Permit #
WQCSD0130
WQCSD0114
WQCSD0057
WQCSD0117
WQCSD0257
WQCSD0116
WQCSD0101
WQCSD0095
WQCSD0098
WQCSD0105
Owner and Facility Name
Brooks Food Group -Brooks Food Group
Charlotte Mecklenburg Schools - Misc Laterals
City of High Shoals CS
Duke Energy Marshall Steam Station
Fallston
Goose Creek Utilities Fairfield Plantation WWTP
Harborside Dev LLC-Midtown T CS
Kennerly Dev. Group LLC-Boardwalk Villas CS
Kennerly_Dev. Group LLC-Kings Point CS
Kennerly Dev. Group LLC-Moon Bay Condos CS
Kennerly Dev. Group LLC-Schooner Bay CS
enner y (VOITUSTretereDev. Group LLC-Spinnaker Point CS
Kingstown
Lake Norman -South Point CS
Lake Norman -Villas S Harbour CS
Lake Norman -Vineyard Pt Resort CS
WQCSD0258
WQCSD0112
WQCSD0104
WQCSD0102
Permit #
WQCSD0064
WQCSD0097
WQCSD0120
WQCSD0019
WQCSD0024
WQCSD0038
WQCSD0002
WQCSD0049
Owner and Facility Name
Lincoln County CS
Martin Dev Gp-N Point & Portside CS
Martin Marietta Mallard Creek
Town of Richfield CS
Town of Grover CS
Town of McAdenville CS
Town of Ranlo CS
Town of Spencer Mountain CS
WQCSD0252 All spills which do not have a permit
number assigned

Collection System. SSO 24-Hour Notification
Collection System: Number and Name WQCS# (:)00-14:,
Incident Number from BIMS 2mo (3C
Incident Reviewed (Date)::.
Incident Action Taken: BPJ
•-r-NOV-2010-DV • IC22-O •
Spill Date Time di.4 0 a:D/ p
Reported Date q(tS- Time l �(S am/gym .
6 CLS
Reported To SWP Staff or EM Staff
...Reported By
..N mil,
Address of Spill .22 S. 1 • S I-
• :County
Cause of SpillTt S
City Jart,i4
Total Estimated Gallons • 60 v
StreamGI-, Fish Kill: Yes Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad
®S--LAI M o
Phone
Est...Galto Stream 60

Permit # ..
WQCS00253
WQCS00196
WQCS00233
WQCS00001
WQCS00016
WQCS00046
WQCS00107
WQCS00089
WQCS00221
WQCS00326
WQCS00088
WQCS00017
WQCS00020
WQCS00327
WQCS00036
WQCS00040
WQCS00164
WQCS00026 '
WQCS00059
WQCS00044
WQCS00019
WQCS00037
WQCS00030
WQCS00149
Owner and Facility Name
Bradfield Farms Water Company CS
Carolina Water Service Cabarrus Woods CS
Carolina Water -Service HembyAcres CS
Charlotte -Mecklenburg CS.
City of Albemarle CS
City of Belmont CS
City of Bessemer City CS
City of Cherryville CS.
City of Claremont CS
City of Concord CS
City of Conover CS
City of Gastonia CS
City of Hickory CS
City of Kannapolis CS
City of Kings Mountain CS
City of Lincolnton CS
City. of Lowell CS
City of Monroe CS
• City of Mount Holly CS
.City of Newton CS .
City of SalisburyCS
City of Shelby CS
• City of Statesville CS
• East Lincoln CS
Permit # Owner and Facility Name
WQCS00171 Greater Badin CS
• WQCS00322 Aqua Country Woods East CS
WQCS00222
WQCS00341
WQCS00231
WQCS00058
WQCS00165
• WQCS00342
WQCS00328
WQCS00343
WQCS00310
WQCS00120
WQCS00344
WQCS00043
WQCS00125
WQCS00153
WQCS00190
WQCS00325
WQCS00180
WQCS00135
WQCS00258
WQCS00345
WQCS00054
W QCS00009
Town of Boiling Springs CS
Town of China Grove CS
Town.of Cleveland CS
Town of Cramerton CS
Town of Dallas CS
Town of E. Spencer CS
Town of Harrisburg CS
Town of Landis CS
Town of Longview CS
Town of Maiden CS
Town of Marshville CS
Town of Mooresville CS
Town of Mt Pleasant CS.
Town of Norwood CS
Town of Oakboro CS •
Town of Stanfield CS
Town of Stanley CS
Town of Taylorsville CS
Town of Troutman CS
Town of Wingate CS
Union County CS
WSA Cabarrus Co. CS
Deemed Permitted. ••
Permit # . Owner and Facility Name
WQCS00130 Brooks Food Group -Brooks Food Group
WQCSD0114 Charlotte Mecklenburg Schools Misc Laterals
WQCSD0057 City of High Shoals CS .
WQCSD0117 Duke Energy Marshall Steam Station
WQCSD0257 Fallston
WQCSD0116 • Gopse Creek Utilities Fairfield Plantation WWTP
WQCSD0101 Harborside Dev LLC-Midtown T CS .. •
WQCSD0095 Kennerly Dev. Group LLC-Boardwalk Villas CS
WQCSD0098 Kennerly Dev, Group LLC-Kings Point CS
WQCSD0105 Kennerly Dev. Group LLC-Moon Bay Condos CS
WQCSD0107 Kennerly Dev. Group LLC-Schooner Bay CS
WQCSD0099 Kennerly Dev. Group LLC-Spinnaker Point CS
WQCSD0258 Kingstown
WQCSD0112 Lake Norman -South Point CS •
WQCSD0104 Lake Norman -Villas S Harbour CS
WQCSD0102 Lake Norman -Vineyard Pi Resort CS
Permit # Owner and Facility Name
WQCSD0064 Lincoln County CS
WQCSD0097 Martin Dev Gp-N Point & Portside CS
WQCSD0120 Martin Marietta Mallard Creek •
WQCSD0019 Town of Richfield CS
WQCSD0024 Town of Grover CS
WQCSD0038 Town of McAdenville CS
WQCSD0002 Town of Ranlo CS
WQCSD0049 Town of Spencer Mountain CS
WQCSD0252 All spills which do not have a permit
number assigned

APR-5-2010 12:41 FROM:BELMONT PUBLIC WORKS 7047493359 TO:7046636040 P.1/5
,.%:g pulses , .
City of f klmaiit Pul)lic Works
6 i�
11 .. _,
,fi n`
:,• ' - 1 1401 E, Catawba Sr„ ` Belmont, NC 28012 ' www.citvofbelmont.org
,;",
'�.na 4` . 1 e1cphonc 709,901-2073 * Fax 704.749,33.59
Distribution / Collections
To: Lonnie Schneider
From: Danny.Whisnant
Fax: [phone]
Pages: 5
Phone: [phone]
Date' 04/05/1.0
Re: 550
Cc:
Comments:

APR-5-2010 12:42 FROM:BELMONT PUBLIC WORKS 7047493359
TO:704663E040 P.2/5
Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
V 112009 PART I
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: C.54500+4' (WQCS# if active, otherwise use WQCSD#)
Facility ?O1f ( /W'J1 S .S-9,4
'P/rl Incident #
Owner: Ca✓11-O j�l,~ .-%. Region:
City: C/,t-lpr► ,f - ES
County: - S- o ri
Source of SSC (check applicable) : ES Sanitary Sewer 0 pump Station / Lift Station
SPECIFIC location of the SSO (be consistent in description from past,rep_o`rt^s or documentation - l.e. PumpStation8,
/%?an r a %` .P sJ' /'s'6 S �/'c-c-7� c+ �' I�Gti /dui y
Manhole et west/0 & Bragg Street, etc.) : j
Manhole# f1,1/ fir
• Latitude (degrees/minute/second): N/ 04 . Longitude(degrees/minute/second)•
Incident Strtod It dy-6,5---- /o Time: 9''94drin Incident EndDt: d9-Q5c20/0
(mm-dd-yyyy) hh:mm AM/PM (mm•dd•yyyy)
Estimated volume of the SSO' 5'606 gallons Estimated Duration (Round to nearest hour):— / A r
1'fA1
Time. ...._do er.oii
hh:mm AM/PM
Describe how the volume was determined; 7.g p1
Woothor conditions during 88O ovont:�' " % -
Did SSO reach surface waters? ® Yes 0 No❑ Unknown Volume reaching surface waters (gallons): -6, p get /
Surface water name' t3+04a e r Coo C_ Irx.
Dld 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:
❑ Severe Natural Condition 121 Grease ❑ Roots
❑ Inflow and Infiltration 0 Pump Station Equipment Failure ❑ Power outage
❑ Vandalism IS Debris in line ❑ Othor (Please explain in Part 11)
❑ Pip* Failure (13roak)
24-hour verbal notification (name of person Contacted) La^11 r C
DWQ ❑ Emergency Mgmt. Date (mm-dd-yyyy) Q4/44/0 Time (hh:mm AM/PM): %1-5-4,'!r'7
If an S50 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 shell 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
water, a public notiso shall bo published within 10 days and proof of publication shall be provided to the Division within 30 days.
Rorer 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 Permlttee
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 abovo 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 11 IS COMPLETED, A SIGNATURE 15 REQUIRED AT THE END OF THIS FORM.
CS-SS0 Form Page 1

ti
APR-5-2010 12:42 FROM:BELMONT PUBLIC WORKS 7047493359 TO:7048636040 P.3/5
Grease (Documentation such as cleaning, inspections, enforcement actions,past overflow reports,
educational material end distribution date, etc. snould be avauabie upon request.) {
When was the last time this specific line (or wet well) was Cleaned? Dece c.r. "eon s'
Co you have an enforceable grease ordinance that requires new or retrofit of grease traps/interceptors?
Fit YeJ Np❑NA©NE
Have there been recent inspections and/or enforcement actions taken on nearby restaurants or other ❑ Ye24 No O NAO NE
nonresidential grease contributors?
Explain.
Have there bean other SSds or blockages in this area that were also caused by grease?
Wien?
' If yes, describe them:
Y
oDNAONE
Have Meaning and inspections ever boon increased at this location?
Explain.
Have educational materials about grease been distributed in the past?
Ye No O MAO NE
tgVe. NoONAONE
When? a,`rw0's tfectr
and to whom? Ail i'cled<4.
Explain?
Cf'0.5� CpQbt:ri i A..Scsk L r. v_kJ r �L(l� T"Wi �C Q. 9 ecer"
if the SSO occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation?
Were the floats clean? 0 YeE3 No 0 MAO NE
Comments;
CS-SSO Form Page 4

APR-5-2010 12:42 FROM:BELMONT PUBLIC WORKS 7047493359 TO:7046636040 P.4/5
Debris in line (Rocks, sticks, rags and other items net allowed in the collection system, etc.)
What type of debris has been found in the line?
R0.cS
Suspected cause or source of debris.
t
Are manholes in the area secure and intaCt?
Yet❑ No 0 NAO NE
When was the area last checked/cleaned? 1C�r` { ,960
Have cleaning and inspections ever been increased at this location due to previous problems with debris? ❑ YcTE No ❑ NAO NE
Explain:
Are appropriate educational materials being developed and distributed to prevent future similar ❑ Yerj No ❑ NA
occurrences?
Comments:
NE
CS-SSO Form Page 11

APR-5-2010 12:43 FROM:BELMONT PUBLIC WORKS 7047493359 TO:7046636040 P.5/5
ystem Visitation
oRc
YCS
Backup ❑ vim
Name:
Cert#
Date visited:
Time visited:
How was the SSO remediated (i.e_ Stopped and cleaned up)?
Cr\mi li r•-P Qy Lecs,, ..
Asa representative for the responsible party, I certify that the information contained in this report is true and accurate
The best of my knowledge. -.
Person submitting claim:t,‘,,x �}1 . rtia Date: 9 . g D /0
Signature:
Title: 'b/rrlyotil"Con;rt-tri+ B'`1-
,.ckvp C_alIet4tnINS aR.0
Telephone Number: 64--'0J - c 07 a
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 Fomr Page 15

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# COO*
Incident Number from BIMS aOw0/51
Incident Reviewed (Date):
Incident Action Taken: BPJ
1OV-2008-DV 02=20
Spill Date - 74/
Reported Date 1%4
Time 7 - am/ pm
Time /OLig am/ pm
Reported To. SWP Staff or EM Staff
Reported By ,/f / auES/7u± Phone 0- V - ,�
Address of SpiII 4,09. % Aci-M d/OIL.Q.aolp/wcie-ice.Z19
County 60571rZ City v r027
4cec3
Total Estimated Gallons — 5 `ICJ
Cause of Spill
Stream 466 ettel. Fish Kill: Ye
. Est. Gal to Stream j (0
Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
V 112009 PART I
This form shall be submitted to the appropriate 1')WQ Regional Office within five clays of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number : [ $Qpe'i?a (WQCS# if active, otherwise use WQCSD#)
Facility: L'eal,Ae4-tbn Sys-kei'l Incident# ,„.,,,,.-
Owner C•r. a -Re_1/21.'cn-4- ,.. Region:
County: -C.- - e r1
. city: l m,' n 4-
Source of SSO (check applicable) : IN Sanitary Sewer ❑ Pump Station / Lift Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation - i.e. Pump Station 6, /
Manhole at Westall & Bragg Street, etc.) : r°r'5 i,-{- crP -y 06 jJ1-`'' 7. PIP i n �remiLoit ales-ett.r r-- ` r'-"7�
�
Manhole# /r/J9
Latitude (degrees/minute/second);
Incident Started Dt: d V-.xl-o/4%d Time: 9'',.5 (Innc-diddeyynt E)nd t: pif"v--?Ofo Time: id �3°%57/V
(mm-dd-yyyy) hh:mm AM/PM
nh:mm AM/PM!
estimated volume of the SSO: .. S340 gallons Estimated Duration (Round to nearest hour): / (°/
describe how the volume was determined: 750 pee" Mi r-,U
Weather conditions during SSO ovonnttf r �cd y
DId SSO reach surface waters? Cal Yes Q NOD Unknown Volume reaching surface waters (gallons): 5 ,3ep qq /
Surface water name: Ab(r`f° k J
Did the SSO result in a fish kill? ❑ YestZNo❑ Unknown If Yes, what Is the estimated number of fish killed? _
SPECIFIC ceuse(s) of the SSO: V'
0 Severe Natural Condition ® Grease ❑ Roots
0 inflow and Infiltration 0 Pump Station Equipment Failure 0 Power outage
❑ Vandalism 3 Debris in line 0 Other (Please explain in Part I1)
❑ Pipe Failure (Break) /
t�
24--hourverbal notification (name of person contacted) t^r"5 �-'`=`-'-c-
ma
,t1t DWQ ❑ Emergency Mgmt. Date (mm-dd-yyyy):d y -e2l .0/0 Time (hh:mm AM/PM)' Af)' S18-an1
/4
Longitude(degrees/minute/second)
If en SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143.215,1C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall Issue a press release within 4$-hours of first Knowledge to all print and electronic news media providing general
coverage In the county-where-t a discharge occurred. When 15,000 gallons or morn of untreated wastewater enters surface
waters, a public notice shall bo published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to thi3 feferericTad 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 (Junior:straled Met.
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 Permitter
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Pert 11 must bo completed to provido 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 (1 IS COMPLETED, A SIGNATURE IS REQUIRED AT THE E D O1= THIS FORM.
CS-5S0 Form Y _ Page 1
S/z'd 0t092991 L:0i 6S22617LtaL S>NOM OI1Bld 1NOW188:WOzld 90:IT aT02-T2-�Idtd

rii
Grease (Documentation such as cleaning, Inspections, enforcement actions, past overflow reports,
educational materlai and dfstributron crate, etc. should be available upon request.)
Whon was the last time this Spedfic lino (or wet wall) was cleaned? 3 — d 3 —/Q
Do you have an enforceable grease ordinance that requires new or retrofit of grease traps/Interceptors?
RIYee NopNAENE
Have there been recent inspections and/or enforcement actions taken on nearby restaurants or other YeE No ❑ NA❑ NE
nonresidential grease contributors?
Explain.
Have there been other SSOs or blockages in this area that were also caused by grease? yY Ye No 0 NAD NE
When?
' If yes, describe them:
pe.-Txeca. .
Have cleaning and inspections ever been Increased at this location?
Explain.
Yneg Nu ❑ NA❑ NE
Have educational motsripls about groom) been distributed in the pest? — (EY—Z No ❑ NA D NE
When?
74t.;ce t
and to whom? ek(}p5 7,2 1s , uCSine.f.leS
Explain?
gr se 2 bb) n. t` wo--tr 601 ,Lw1c ca y e r
If the SSO occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation?
Were the Floats clean? ❑ Yea No ❑ NA❑ NE
Comments:
CS-SSO Farm
Page 4
S/`='d O1709299t7OL:Ol 6S226t?L170L SNelOM 3Il8ld INOW138:Waid LO:TT OTOZ-T2- idU

Oebris 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?
rc s
Suspected cause or source of debris.
Are manholes in the area secure and intact? ve] No Q NAD NE
When was the area last checkedfcleaned?
Have cleaning and Inspections ever been increased at this location due to previews problems with debris? ❑ Ye
Explain;
DONA1NE
Aro appropripto educational materials being developed and distributed to prevent future similar YeCI No NA❑ NE
occurrences?
Commonta!
CS-SSO Form Page 11
S/b'd eb0929917eL:01 6S226bLi7eL S)IIDM 9I18fld 1NOW188:WOdd LO:TT OT02-I2- Idid

APR-21-2010 11:07 FROM:BELMONT PUBLIC WORKS 7047493359 TO:7046636040 P.5/5
S6 eBed
ua.a0J OSS.So
-(pasn d! .palaIdwoo CI woo)
s!y1 Jo Aa4ue aiuoJPoIe uogm poleaaue6'quo si Jegwnu;ueppui eq) iequnu luepioul eql o eaueaalel 4;im dg$ zya Jo eBpeimawi
1say }o s,Cep eny uJ41LM ea 0 Ieua!6oa uoisiniO alalada,rdde 041-a11uee eq pinoyc p04.11wqrla aq a; poJrsap uol;euuaJu! lauo!n+pp0 4oV
1Od0-Nave
Q'e - ; h -1- Q L4 :JegwnN euogdelei
;a1n;eAs
+v`"01-4 $ r C'ta,u`v<:::),_ Bui;;iwgns uosJaa
-a8petmawi Aw jo }sag a J1
o; e;eanooe pue Gm; JodaJ sly; u! peU!e;uoo UOgetwoj I ay11e41 f}!laaa 1 'Aped aigsuodsea e4; aa; enpe;uasa iii e ev
i_c4296
,IN,Qtl 5' NCO
soAg
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L(dn peueeio pue peddo;S 'e l) po)elpouoJ OS$ a41 ooM MOH
:pa11sln
:pelisin 914Q
4}ae0
:eweN
dmiaee
02;i0
uo!}e;!s!A uue;sl§

Collection System SSO 24-Hour Notification
Collection System: NtJmber and Name WQCS# ( )cU
Incident Number from BIMS DtDop ( ok.3
Incident Reviewed (Date):
Incident Action Taken: BPJ
NOV-2010-DV • CAL5
Spill Date
Reported Date 3(2_
Time t3� am/i
Time et D°i/ pm
Reported To SWP Staff or EM Staff L_S :
Reported By ;s,,¢ Phone
Address of Spill G�s� ��F S to r--
_County • Cs.p,b6,)• City.,.�
Cause of Spill fir; S
Total Estimated Gallons -3C) J Est. Gal to Stream St
Stream Fish Kill: Yes EI.Number • Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

Permit#
WQCS00253
WQCS00196
WQCS00233
WQCS00001
WQCS00016
WQCS00046
WQCS00107
WQCS00089
WQCS00221
WQCS00326
WQCS00088
WQCS00017
WQCS00020
WQCS00327
WQCS00036
WQCS00040
WQCS00164
WQCS00026
WQCS00059
WQCS00044
WQCS00019
WQCS00037
WQCS00030
WQCS00149
Owner and Facility Name
Bradfield Farms Water Company CS
Carolina Water Service Cabarrus Woods CS
Carolina Water Service Hemby Acres CS
Charlotte -Mecklenburg CS
City of Albemarle CS
City of Belmont CS
City of Bessemer City CS
City of Cherryville CS.
City of Claremont CS
City of Concord CS
City of Conover CS
City of Gastonia CS
City of Hickory CS
City of Kannapolis CS
City of Kings Mountain CS
City of Lincolnton CS
City of Lowell CS
City of Monroe CS
City of Mount Holly CS
City of Newton CS
City of SalisburyCS
City of Shelby CS
City of Statesville CS
East Lincoln CS
Permit #
WQCS00171
WQCS00322
WQCS00222
WQCS00341
WQCS00231
WQCS00058
WQCS00165
WQCS00342
WQCS00328
WQCS00343
WQCS00310
WQCSoo120
WQCS00344.
WQCS00043
WQCS00125
WQCS00153
WQCS00190
WQCS00325
• WQCS00180
WQCS00135
• WQCS00258
WQCS00345
'WQCS00054
WQCS00009
Owner and Facility Name
Greater Badin CS
Aqua Country Woods East CS
Town of Boiling Springs CS
Town of China Grove CS
•Town.of Cleveland CS
Town of Cramerton CS
Town of Dallas CS
Town of E.-Spencer CS
Town of Harrisburg CS
Town of Landis CS
Town of Longview CS
Town of Maiden CS
Town of Marshville CS
Town of Mooresville CS
Town of Mt Pleasant CS.
Town of Norwood CS
Town of Oakboro CS •
Town of Stanfield CS
Town of Stanley CS
Town of Taylorsville CS
Town of Troutman CS
Town of Wingate CS
Union County CS
WSA Cabarrus Co. CS
Deemed Permitted
Permit #
WQCSD0130
WQCSD0114
WQCSD0057
WQCSD0117
WQCSD0257
WQCSD0116
WQCSD0101
WQCSD0095
WQCSD0098
WQCSD0105
WQCSD0107
WQCSD0099
WQCSD0258
WQCSD0112
WQCSD0104
WQCSD0102
Owner and Facility Name
Brooks Food Group -Brooks Food Group
Charlotte Mecklenb'urg Schools - Misc Laterals
City of High Shoals CS
Duke Energy Marshall Steam Station
Fallston • 1
Gopse Creek Utilities Fairfield Plantation WWTP
Harborside Dev LLC-Midtown T CS
Kennerly Dev.. Group LLC-Boardwalk Villas CS
Kennerly Dev, Group LLC-Kings Point CS •
Kennerly Dev, Group LLC-Moon Bay Condos CS
Kennerly Dev. Group LLC-Schooner Bay CS
Kennerly Dev. Group LLC-Spinnaker Point CS
Kingstown
Lake Norman -South Point CS
Lake Norman -Villas S Harbour CS
Lake Norman -Vineyard Pt Resort CS
Permit #
WQCSD0064
WQCSD0097
WQCSD0120
WQCSD0019
WQCSD0024
WQCSD0038
WQCSD0002
WQCSD0049
Owner and Facility Name
Lincoln County CS
Martin Dev Gp-N Point & Portside CS
Martin Marietta Mallard Creek '
Town of Richfield CS
Town of Grover CS
Town of McAdenville CS
Town of Ranlo CS
Town of Spencer Mountain CS
WQCSD0252 All spills which do not have a permit
number assigned

Mar 02 10 02:12p
■
City Of Belmont
7048250514 p.2
Form CS-SSO
C Collection System Sanitary Sewer Overflow Reporting Form
i a V 112009 PART l
This form shall be Submitted -to the appropriate OWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number : Lc.)' ( 4 Cl��./.6.
(WgCS# if active, otherwise use WQGSD#)
Facility Cr>(f r2,f-,-1 n.7 5 / j ci-C " . Incident #
Owner: i lid.f' r , tit Y''.-/O.' t
Region;
city; -A/.'/ii-'/' / , — County.
Source of SSO (check applicable) : ® Sanitary Sewer 0
Pump Station 1 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.) : / �'�' OfC- t�'.C".'i.Gf -r.kr/.-; r `1 fnf Jc >/� [(- Sc't f.e.',41 -54 f 4"
Manhole# /✓///
• Latitude (degrees/minute/second):
Incident Started Dt
(rem- dd-yyyy)
Estimated volume of the SSQ• ,
t j Time; J / j4't;n
hh:mm AM/PM
Longitude(degrees/mi nute/second)-
Incident End Dt: a � i-,•74.)/e/ Time:
(mm-dd-yyyy) hh:mm AMIPM
Slid gallons Estimated Duration (Round to nearest hour): �..
Describe how the volume was determined:
.Yll1n",-7
Weather conditions during SSO event fl2 i1 /ip' C•/c' 'r7 j
Did SSO reach surface waters? 13 Yes❑ Not: Unknown Volume reaching surface waters (gallons): :S' >
Surface water name: /` /!<<" 5 . C r" f-C'
Did the SSO result in a fish kill? 0 Yes0 No❑ Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
0 Severe Natural Condition 0 Grease ❑ Roots
OInflow and Infiltration ❑ Purnp Station Equipment Failure 0 Power outage
❑ Vandalism C3 Debris in line 0 Other (Please explain in Part Cr)
0 Pipe Failure (Break) �
24-hour verbal notification (name of person contacted} //. l �'f ^' C -',K A nr / r:-/- r
DWQ ❑ Emergency Mgmt.
Date mm-dd- C>r--�:.;2--.24;/ ' C)f: r-r/rt
( yyyyp Time (hh:mm AM/PM)_
If an SSO is ongoing, please notify Regional Office on a daily basis until SSP 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-WW87176-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 -e eF-rgrtced statute for further detail.
The Director, Division of Water Duality may take enforcement action for SSOS that are required to be reported to Division unless it
is demonstrated thaf:
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 es 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

Mar 02 10 02:12p Cit. Of Belmont
7048250514
p
to pu Bide
City of Belmont Public Works
:,-,;•:.\\,,,,
.4.-.7,:;.:...., ,,,,A.,,
A:.:...;:-'• :4'15eA-4?:1;.'., 1;, ....,.„::.:. ',.;4,,•;„.•.'g ',;2;ia.::',6e,t,A'‘.17,7.71:1:7;:iglariv:•-•.,,.,. •
w
iittpili.,. Catawba St, Belmont, NC 28012 ' www.ciiy.o1)>.cjin(int-4ag
Telephone [phone] ' Fax [phone]
CAR°V Distribution / Colledic.>ns
To: Lonnie Schneider
From: Danny Whisnant
Fax: [phone]
Pages: 4
Phone: [phone]
Date: 03/02/10
Re: SSO
Cc:
Comments:
•
111
fa csi
mile

02:12p City Of Belmont,
7048250514 p.3
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 tine?
n q rq 5 at i ! c.,c'/ ' 1 ^ (•i // . 5/U c: r-544'
Suspected cause or source of debris.
Are manholes in the area secure and intact? I Yefl Na U NA❑ NF.
When was the area last checkedlcleaned?
4;2 u 'a y
Have Weaning and inspections ever been increased at this location duo to previous problems with debris? DeaC]I No 0 NA❑ NC
1/ + i irr.' f % /icd
Are appropriate educational materials being developed and distributed to prevent future similar Ye No O.NAD NE
occurrences?
Comrnents:
CS-SSO Form
Page 11

Mar 02 10 02:13p -0f Belmont
7048250514
System Visitation
ORC
Backup
Name:
Cart#
Date visited:
Time visited:
❑ Yes
Yes
How was the SSO remediated (i.e. Stopped and cleaned up)?
4/41 ,42/t'i'f (4i:I(•.4'°srIll /!r'-fCJ-.v^I' czi..�.-`
Asa 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 c{aim;
0)7 Yt6- L.L.J�e rJ /rei �,
Signature; ,1.;,4ir`
Telephone Number. o / - `AV 73.
Date_ '3 -..7--/ Ci
Title: /-7i-st•J/Jc)fi%•.7 rni/ri-. i�n1
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within rive days of first
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic ontry of this
form is completed, if Used),
CS-SSO Form Page 15

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# CDC--)°4<0
Incident Number from BIMS ad I
Incident Reviewed (Date):
Incident Action Taken: BPJ
NOV-2010-DV
Spill Date ."\°1 1
Reported Date -aH-11.
Time a:• fl am")
Time
Reported To SWP Staff or EM Staff - �-
Reported By \, • Phone
Address of Spill R-P ' . _ . i(A-L9 4'
'County •
CaLrs:e, of Spill
City. P.
Total Estimated Gallons �� Est Gal to Stream
IbC3
StreamAb .�—' Fish Kill: Ye No ► umber Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad.
To: Lonnie Schneider
Fax: 704-663_6040
Phone: [phone]
Re: SSO
Comments:
�T 4 1401 E. Catawba Sr. ' 13clmonl, NC 28(71 `l
Telephone c mvw.rilyofbi.-.1(p901.nti:
ry CAl Phone [phone] - Fax 7O4-8 -0514
Distribution / Collections
From: Danny Whisnant
Pages: 5
Date: 03/04/1Q
Cc:
facsimile

Permit#
WQCSD0130
WQCSD0114
WQCSD0057
WQCSD0117
WQCSD0257
WQCSD0116
WQCSD0101
WQCSD0095
WQCSD0098
WQCSD0105
Permit #
WQCS00253
WQCS00196
WQCS00233
WQCS00001
WQCS00016
WQCS00046
WQCS00107
WQCS00089
WQCS00221
WQCS00326
WQCS00088
WQCS00017
WQCS00020
WQCS00327
WQCS00036
WQCS00040
WQCS00164
WQCS00026 •
WQCS00059
WQCS00044
WQCS00019
WQCS00037
WQCS00030
WQCS00149
Owner and Facility Name
Bradfield Farms Water Company CS
Carolina Water Service Cabarrus Woods CS
Carolina Water'Service HembyAcres CS
Charlotte -Mecklenburg CS
City of Albemarle CS
City of Belmont CS
City of Bessemer City CS
City of Cherryville CS.
City of Claremont CS
City of Concord CS
City of Conover CS
City of Gastonia CS
City of Hickory CS
City of Kannapolis CS
City of Kings Mountain CS
City of Lincolnton CS
City of Lowell CS
City of Monroe CS
City of Mount Holly CS
City of Newton CS
City of SalisburyCS
City of Shelby CS .
City of Statesville CS
East Lincoln CS
Permit #
WQCS00171
WQCS00322
WQCS00222
WQCS00341
WQCS00231
WQCS00058
WQCS00165
WQCS00342
WQCS00328
WQCS00343
WQCS00310
WQCS00120
WQCS00344.
WQCS00043
WQCS00125
WQCS00153
WQCS00190
WQCS00325
WQCS00180
WQCS00135
WQCS00258
WQCS00345
WQCS00054
WQCS00009
Owner and Facility Name
Greater Badin CS
Aqua Country Woods East CS
Town of Boiling Springs CS
Town of China Grove CS
Town.of Cleveland CS
Town of Cramerton CS
Town of Dallas CS
Town of E. Spencer CS
Town of Harrisburg CS
Town of Landis CS
Town of Longview CS
Town of Maiden CS
Town of Marshville CS
Town of Mooresville CS
Town of Mt Pleasant CS
Town of Norwood CS
Town of 0akboro CS
Town of Stanfield CS
Town of Stanley CS
Town of Taylorsville CS
Town of Troutman CS
Town of Wingate CS
Union County CS
WSA Cabarrus Co. CS
Deemed Permitted
Owner and Facility Name
Brooks Food Group -Brooks Food Group
Charlotte Mecklenburg Schools - Misc Laterals
City of High Shoals CS .
Duke Energy Marshall Steam Station
Fallston
Gopse Creek Utilities Fairfield Plantation WWTP
Harborside Dev LLC-Midtown T CS
Kennerly Dev. Group LLC-Boardwalk Villas CS
Kennerly Dev. Group LLC-Kings Point CS
Kennedy Dev. Groin i ^"--- "
Mar 04 10 02:20p
city Of Belmont
v1ATE•
�.
i ed•to the appropriate DWO Regional Office within f s of the first knowledge of
the sanitary This form shsewefll be overflow (SSO),
(WQCS# if active, otherwise use WQCSO#)Incident #
���i�
Region:
Permit #
WQCSD0064
WQCSD0097
WQCSD0120
WQCSD0019
WQCSD0024
WQCSD0038
WQCSD0002
WQCSD0049
Owner and Facility Name
Lincoln County CS
Martin Dev Gp-N Point & Portside CS
Martin Marietta Mallard Creek
Town of Richfield CS
Town of Grover CS
Town of McAdenville CS
Town of Ranlo CS
Town of Spencer Mountain CS
7048250514
Permit Number : �' (> /.If.�t�if ��
Facility:
Owner:
City:
Source of SSO (check applicable) :
ion from
past
repo
SPECIFIC location of the SSO (be consistent in description frpast,copo
Manhole at Westall & Bragg Street, etc.)—
Manhoie#
p ' 2 .....
Form CS-SSO
Sewer Overflow Reporting Form
Collection System Sanitary S PART
V 112009
• Latitude (degrees/minute/second): —
/�J
incident Started Dt
(mm-dd-yyyy)
Estimated volume of the S$0: .
Describe how the volume was determined:
Weather conditions during SSO eventYQsU Nor t Unknown
Did SSD reach surface waters'? C ' e5 O
rl If Yes. what is the estimated number of fish killed
Surface water name: ® No0 Unknown
Did the SSO result in a fish kill? 0 Yes �,
f.
of the SSO: 0 Roats
SPECIFIC a ere N 0 Grease 0 Power outage
0 Severe Natural Condition 0 pump Station Equipment Failure ; ; part tl)
0 Inflow and Infiltration 0 Other (Please explain n
Debris in line
❑ Vandalism
1 Pipe Failure (Break)
n3 rl / /Lf
24-hour verbal notification (name of person contacted
Date (mm-dd-yyYY)
f]WQ CD Emergency Mgmt,
please notify Regional Office on a daily basis until SSO can be stopped.
If an SSO is ongoing, gallons or more of untreatod wastewater provido inggeneral
Per G-S.hall issue
a press
the responsibleleeWthinparty of a discharge of 1,000 g
and electronic news mediat
Within 4$-hours of first knowledge to all printto tho Division within 3A days -
waters shall issuo a press release gallons or more of untreated wastewater enters surface
waters,
coverage in the cootie wnero rya pub she occurred. When 1 d,p00
waters, a public notice shalt be published within10 days and proof of publication shall be provided
Rof©r to tho reYE3�e� statute for further detail.
f Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless
it
The Director, Division o •..��- e; or
�s (tho dns ri1 e a
ra and caused by factors beyond the reasonable control of the Pormittoo
tho discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge: 1) the exercise of reasonable control.
a) the discharge was exceptional, could not havelbean pro nted by
and/or owner, and the discharge
completed to provide a justification claim for either of then above
besit ation5completo is possible,information
ttn will be the basis
tart 11 must mi F
for the determination of any enforcement action, Therefore, it:is import
PLETED A SIGNATURE IS REQUIRED AT THE ENO OF THIS FORM.
6 r: ; ,-�
county:
Sanitary Sewer ❑ Pump Station /Lit Station $t$tio^ G,
documentation -1,e• Pump ,
. tins r, -tom _..,.(.,
Time:
hi -mini AM/PM
'7 Art
gallons
Longitude(degrees/minutelsecond): L�
�, y.- . ,; I tt Time:
Incident End Dt: hh;mm AM/PM
(mm-dd-yyY� �
Estimated Duration (Round to nearest hour):
-
. -- ..-v..ro r'17 N
Volume reaching surface waters (gallons): / S
Time (hh:mrr+ ANI/PM)

Mar 04 10 02:20p
City 0f Belmont
7048250514 p.3
Pipe Failure (Break)
Pipe 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 lino?
Is the line a "High Priority" line?
_ Last inspection date and findings
/0--2C%fi j
(76 y
Yelp No❑NADNE
❑YatN0❑NA❑NE
Yea No NA❑NE
if a force main then.
Was the break on the force main veritical?
Was the break on the force main horizantal?
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-releaso valve to determine of operable?
When was the last maintenace of the air release performed?
If gravity sewer then,
Does the fine receive flow from a force main immediately upstream of the failed section of pipe?
If yes, what measures are taken to control the hydrogen sulfide production?
O 'Yea No ❑ NAD NE
❑Yet0 No❑NA❑NE
❑Yat❑ No❑NA!:NE
© YeEl No ❑ NAG NE
❑ Yea NOD NA❑ NE
When was the line last inspected or videoed? rr;) ••6 li � __
CS-SSQ Form Page 13

Mar 04 10 02:20p City Of Belmont
7048250514 p.4
If line collapsed, what is the condition of the line up and down stream of the failure?
What type of repair was made?
(e% ;r*r/ �.: Ar-,.., �—i'cf
Is the repair temporary or permanent?
If temporary, when is the permanent repair planned?
Have there been other failures of this line in the past five years? 0 Yea No Q NAD NE
If so, then describe
CS-SSO Form Page 14

Mar 04 10 02:20p City 0f Belmont
7048250514 p.5
System Visitatiori
ORC
Backup
Name:
Cert#
Date visited:
Time visited:
0 Yoe
Yee
j1. } I-\ •, r,..
9) .S'.3 7.T-/
713••.
17r
How was the SSO remediated (i.e. Stopped and cleaned up)?
pl,�>r t ,e4b7c t 'i �c{ ? '411,rt i p ' L;,r,:relf in."rC
Asa 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: '(:)„z•„ .A� Srk.e_r,
Signature: Cs.(:\,„, •
•
tJ
Date: 3
Title: 7¢slr,[,�,•I fin/ er nr,S
S.y^r. ,,•, -iic:•.c k U i" e, r2<_
Telephone Number: 7c_, ,_ — c:i c, t _ ,� L. 7
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within fivo days of first
knowledge of the SSO with reference to the incident number (the incident number is only gencratod whon electronic entry Of this
form is completed, if used).
CS-SSO Form Page 15

Collection System. SSO 24-Hour Notification
Collection System: Number and Name VVQCS#
Incident Number from BIMS 2v( 00 t
Incident Reviewed (Date): .
Incident Action Taken: • BPJ• .
NOV-2010-DV Q Zq
Time /(Z� a/prri
Reported Date • lj `Z.S •. Time
Reported To(S % Staff or. EM. Staff •
Reported By .
Address of Spill
:County '
Cause •of Spill 1064 S •
Total Estimated Gallons • `� S
• City •
Stream . Fish Kill: Yes
• Phone
Est...Gal to Stream •
Number • Species
• Non Required Information:and other comments relating to SSO incident.
. Response time • minutes . Zone Map Quad

Permit # ..
WQCS00253
WQCS00196
WQCS00233
WQCS00001
WQCS00016
WQCS00046
WQCS00107
WQCS00089
WQCS00221
WQCS00326
WQCS00088
WQCS00017
WQCS00020
WQCS00327
WQCS00036
WQCS00040
WQCS00164
WQCS00026 '
' WQCS00059
WQCS00044
WQCS00019
WQCS00037
WQCS00030
WQCS00149
Owner and Facility Name
Bradfield Farms Waler Company CS
Carolina Waler Service Cabarrus Woods CS
Carolina Water -Service Hemby Acres CS
Charlotte -Mecklenburg CS
City of Albemarle CS • •
City of Belmont CS
City of Bessemer City CS
City of Cherryville CS.
City of Claremont CS
City of Concord CS
City of Conover CS
City of Gastonia CS •
City of Hickory CS •
City of Kannapolis CS
City of Kings Mountain CS
City of Lincolnton CS
City of Lowell CS.- ' •
City. of Monroe CS
'City of Mount Holly CS
•.City of Newton CS .
.City of Salisbury CS
City of Shelby CS .
. City of Statesville CS
• East Lincoln CS
Permit #
WQCS00171
WQCS00322
WQCS00222
WQCS00341
WQCS00231
WQCS00058
Owner and Facility Name
Greater Badin CS
Aqua Country Woods East CS
Town.of Boiling Springs CS
Town of China Grove CS
Town.of Cleveland CS
Town of Cramerton CS
WQCS00165 Town of Dallas CS
' WQCS00342 Town of E. Spencer CS
. WQCS00328 Town of Harrisburg CS
•WQCS00343 Town of Landis CS
WQCS00310 Town of Lorigview CS
. WQCS00120 Town of Maiden CS
WQCS00344 Town of Marshville-CS
WQCS00043 Town of Mooresville CS
WQCS00125 Town of Mt Pleasant CS.
WQCS00153 Town of Norwood CS
WQCS00190 Town of Oakboro CS • .
WQCS00325 Town of Stanfield CS
WQC800180 Town of Stanley CS
WQCS00135 Town of Taylorsville CS
WQCS00258 • Town of Troutman CS
WQCS00345 Town of Wingate CS
•WQCS00054 Union County CS
WOCS00009 WSA Cabarrus Co. CS
Deemed Permitted,
Permits .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
WQCSD0251 Fallslon
WQCSD0116 Goose Creek Utilities Fairfield Plantation WWTP
WQCSD0101 Harborside Dev LLC-Midtown T CS
WQCSD0095 Kennerly Dev. Group LLC-Boardwalk Villas CS •
WQCSD0098 Kennerly Dev, Group LLC-Kings Point CS
WQCSD0105 Kennerly Dev. Group LLC-Moon Bay Condos CS
WQCSD0107 Kennerly Dev. Group LC -Schooner Bay CS •
WQCSD0099 Kennerly Dev. Group LLC-Spinnaker Point CS
WQCSD0258 Kingstown
WQCSD0112 Lake Norman -South Point CS
WQCSD0104 Lake Norman -Villas S Harbour CS
WQCSD0102 Lake Norman -Vineyard Pl Resort CS
Permit#
WQCSD0064
• WQCSD0097
• WQCSD0120
WQCSD0019
Owner and Facility Name
L• incoln County CS •
Martin'Dev Gp-N Point & Portside CS
Martin Marietta Mallard Creek '
Town of Richfield CS
WQCSD0024 Town of Grover CS
WQCSD0038 Town of McAdenville CS
WQCSD0002 Town of Ranlo CS
WQCSD0049 Town of Spencer Mountain CS
WQCSD0252 All spills which do not have a permit •
number assigned

,
• Owner: - L ( b ! . ''
Source of $SO (check applicable) :
Sanitary Sewer ❑ Pump Station / Lift Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation . Le_ Pump Station 5, . L J-
Manhole at Westell & Bragg Street, etc.) : ✓ Q et- Agf%d r/ s
Manhofer>!
Eorrn CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
PART I
This form shall bo submitted to the appropriate DWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number: pCS ea. "96
(W4CS# if active, atherwiae use WQCS114)
Facility; 06IIP.C.4•t`pr\.5 Sr�`~�r°r!� Incident#
Region•
County; -'5 %
Latitude (degrees/minute/second): _
Nfciz
Incident Started OP. �� /C� Time: � 5-crevk
(mm.dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: _� _'o gallons
Describe how the volume was determined: < o4yM
Weather conditions during SSO event; . C/04.1e/ '
Lon gltude(deg tees/minute/second).
Incident tend Dt: 57P-57/6
(mm•dd-yyyy)
Time'
hh:mm AM/PM
Estimated Duration (Round to nearest hour)•
Did SSO reach surface waters? ® Yes ❑ No❑ unknown Volume reaching surface waters (gallons);
Surface water name. 2/.44t eciS rr-tr—r-t1 n /Js44 m. .1„-XIW71/,ldr,'L
Dfd the SSO result in a fish kill? ❑ Yes fijNOD Unknown
SPECIFIC cause(s) of the SSO:
0 Severe Natural Condition
❑ Inflow and Infiltration
Vandalism
❑ Pipe Failure (Break)
24-hour verbal notification (name of person contacted)-- °lit M t'
If Yes, what is the estimated number of fish killed?
❑ Grease
❑ Pump Station Equipment Failure
❑ Debris in line
t�t Roots
t,, f Power -outage
❑ Other (Please explain In Part 11)
ems! DWQ C❑ Emergency Mgmt. Date (mm-dd•yyyy); a a /Q Time (hh:mm AM/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 press reIcase within 443-hours of first knowledge to all print and electronic news media providing genera!
coverage in the county fere# themischarpe occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be putllshed within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the reterenced 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 demons ra e
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, end 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 ebovo situations. This information wilt be the basis
for the determination of any enforcement action, Therefore, it Is important to be as complete as possible.
WHETHE R OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS.SSO Form
Page 1
17/2' d 0t09299170L :01 6S22617Lt70L S)li'iOM 9I18fld INO1,1188 : Waid 8S :2I OT02-92-) N

City of Belmont
Distribution & Collections
1401 East Catawba Street
Belmont, NO 28012
Phone: [phone]
FACSIMILE TRANSMITTAL
To: Lonnie Sehneide '
Fax #: [phone]
From: Danny Whisnant
Fax #: [phone]
Pages: 4
Date: May 26, 2010
Re: SSO
• If you do not receive all pages indicated, please call us at [phone]
17/ I ' d 0{709299170L : 01 6S22617L1702. S)IIOM OIlRld 1NOW988 : NO d LS : EI 0TO2-92-J,dW

Roots
Da you have an active mor control program on the lino / area In question?
Describe
Yo0 No ❑ NAD NE
Have cleaning and Inspections ever been Increased at this location because or roots? Ye
Explain:
Never cLY R1.'0ktewS Q+ 1.,s
What corrective actions have been accomplished at the SSO location (and surrounding system if
associated with the SSO)?
w k W e 1 c S° (1.. Q rce c -ort.cj d k 4-)1r. w r /II et PI
What corrective actions are planned at the $$O location to reduce root intrusion?
n f AA c +fir
Has the line been smoke tested or videbed within the -Past year? 0 Y0.0 NAO NE
00NA❑N$
If Yes, when?
Comments:
Wil
CS -$SO Form
logs is
ecoe fc14
Page 5
b/E'd O O9299baL:01 6S226bLf IL S)IZIOM OI1Bld 1N0W188:WOZld 8S:2T 02-92-/ L4

System Visitation
ORC
backup
Name:
Cert#
Qate visited:
Time visited:
How was the SSO remediated (i.e. Slopped and cleaned up)7
Asp representative for the responsible pa
e 67 st Of my knowledge.
Person submitting claim:
Signature:
Telephone Number: 70 5/_ 9,/
Any additional information desired to be
knowledge of the SSO with reference to
forth Is completed, it used).
CS•SSO Form
s-
_ 2 4 '73
cj Yes
/11
Yee
07 /6
// Siz.Sc7..,
I certify that the inforrnr don contained In this report is true and accurate to
flTCQ,..71'
Title:
Date: a /C7
submitted should be sent , the appropriate Division Regional Office within five days of first
the Incident number (the i cident number is only generated when electronic entry of this
Page 15
b/b'd ab09299t7OL:01
6S226'L170L S)li iOM OI-18nd 1NOW188: WaZld 8S :ET 0 T02-92-AUW

Collection System. SSO 24-Hour Notification
Collection System: Number and Name
Incident Number from BIMS ' -
Incident Reviewed (Date):
Incident Action Taken:
BPJ•
NOV-2010-DV 0
Spill Date
Reported Date
. Time •.
g°(--- /pm
2C) 6:pm.
Reported To SWP Staff _or. EM. Staff •
. :.Reported By •
ti
Address of Spill •
• :C'ounty. .
Cause •of Spill S
Total. Estimated Gallons •5 �M�,
_ ` ~GLc
Stream qc12a`(L. Fish Kill: Yes Vo Number • Species
• City
Est .Gal to Stream .5C)v `•
. Non Required Information and other comments relating to SS0 incident:
Response time
• minutes • Zone
Map•Quad• •

Permit # ..
WQCS00253
WQCS00196.
WQCS00233
WQCS00001
WQCS00016
WQCS00046
WQCS00107
WQCS00089
WQCS00221
WQCS00326
WQCS00088
WQCS00017
WQCS00020
WQCS00327
WQCS00036
WQCS00040
.WQCS00164
WQCS00026
WQCS00059
WQCS00044
WQCS00019
WQCS00037
WQCS00030
WQCS00149
Owner and Facility Name
Bradfield Farms Water Company CS
Carolina Water Service Cabarrus Woods CS
Carolina Water•Service Hemby Acres CS
Charlotte -Mecklenburg CS.
City of Albemarle CS
City of Belmont CS
City of Bessemer City CS
City of Cherryville CS.
City of Claremont CS ,
City of Concord CS
Oily of Conover CS
City of Gastonia CS • •
City of Hickory CS •
City of Kannapolis CS
City of Kirigs Mountain CS
City of. Lincolnlon CS
Cily of Lowell CS •
City of Monroe CS
City of Mount Holly CS
:City of Newton CS .
.City of SalisburyCS
City of Shelby CS .
City of Sla(es.ville CS •
East Lincoln CS
Permit # Owner and Facility Name
WQCS00171 Greater Badin CS
• WQCS00322 Aqua Counlry Woods East CS
WQCS00222 • Town.o.f Boiling Springs CS
. WQCS00341 Town of China Grove CS
WQCS00231 Town.of Cleveland CS
WQCS00058 Town of Cramerton CS
• WQCS00165 Town of Dallas CS
• WQCS00342 Town of E.• Spencer CS
• . WQCS0032B Town of Harrisburg CS
•WQCS00343 Town of Landis CS
WQCS00310 •Town of Longview CS
. WQCS00120 Town o(Maiden CS
WQCS00344. Town of MarshvilleCCS
• WQCS00043 Town of Mooresville CS
WQCS00125 Town or Mt Pleasant CS.
•• WQCS00153 Town of Norwood CS
WQCS00190 Town of 0akboro CS
WQCS00325 Town of Stanfield CS
• WQCS00180 .Town of Stanley CS
WQCS00135 Town of Taylorsville CS
• • WQCS0025B • Town of Troutman CS
WQCS00345 Town of Wingate CS
•WQCS00051 Union County CS
WQCS00009 WSA Cabarrus Co. 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
WQCSD0257 Fallslon ..
WQCSD0116 • Gopse Creek Utilities Fairfield Plantation WWTP
WOCSD0101 Harborside Dev LLC-Midtown T CS •
WQCSD0095 Kennerly Dev. Group LLC-Boardwalk Villas CS
•
WQCSD0098 Kennerly Dev, Group LLC-Kings Point CS
WQCSD0105 Kennerly Dev. Group LLC-Moon Bay Condos CS
WQCSD0107 Kennerly Dev. Group LLC-Schooner Bay CS
•
WQCSD0099 Kennerly Dev. Group LLC-Spinnaker Point CS
WQCSD0258 Kingstown
WQCSD0112 Lake Norman -South Point CS •
WQCSD0104 Lake Norman -Villas S Harbour CS
WQCSD0102 Lake Norman -Vineyard Pt Resort CS
Permit # Owner and Facility Name •
WQCSD0064 • Lincoln County CS -
WQCSD0097 Martin'Dev Gp-N Point & Portside CS
WQCSD0120 Martin Marietta Mallard Creek '
WQCSD0019 Town of Richfield CS
WOCSD0024 Town of Grover CS .
WOCSD0038 Town of Mc. Adenville• CS
WQCSD0002 Town of Ranlo CS
WQCSD0049 Town of Spencer Mountain CS
WQCSD0252 All spills which do not have a permit •.
number assigned

��04 WA7 �QG
='>!1 /loll �L1
Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
PART 1
This form shall be submitted to the appropriate OWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number : c.5 060 yt4 (WQCS# If active, otherwise USG WQCSD#)
Facility: COl e04/ rlr. ,; S•t1j-,--x Incident # ? 21�l --9 2_
• owner; ��'Y..�T Ic-%+,. r I- �-
City: • • hn-E-. ,
Source of SSO (check applicable) ; Sanitary Sewer 0
Pump Station / Lift Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation - i.e. Pump laden 6,
Manhole at Westall & Bragg Street, etc_) : of
Manhole# rU14.
Latitude (degrees/minute/second):
ICllt�i
Incident Started DI: DG =,2 pia Time: - do c1^^
(mrYm.dd-yyyy) hh:mrn Aht/PM
Estimated volume or the S$O: ¢ n gallons
Oescrlbe how the volume was determined: �d f%!+7
Weather conditions during SSO event:. 0
Did SSO reach surface waters? E Yes No❑ Unknown
Surface water name' .L1r2LCe14brrt. Aim,'r r`n /iafl, ,lac/p
Did the SSO result in a fish kill? ❑ Yes ti Not_! Unknown
SPECIFIC causes) of trio SSO:
0 Severe Natural Condition
t, Inflow and Infiltration
0 Vandalism
0 Pipe Failure (Break)
24-hour verbai notification (name of person eontacted),.%..S^ L�1P3i �--+. C•I rie C^f
Region: �-
County: C7r-1_
Longltude(degrees/minute/second)• - "_/(
Incident End tat; 64'-a6'42a/2 Tirhe3:
(mrn-dd.yyyy) hh:mm AM/PM
Estimated Duration (Round to nearest hour)' - l
Volume reaching surface waters (gallons):
FfACC&
If Yes, what is the estimated number of fish killed?
0 Grease
❑ Pump Station equipment Failure
❑ Debris in line
ac
al Roots
0 Power outage
Q Omer (Please explain in Part 1t)
tom► Dwa ❑ Emergency Mgrnt, Date (min-cld-yyyy)-.4&-29-1.1_0JO Time (hh:mmAM/PM)• 5:.Cl cx•ss
If an SSO is ongoing, please notify Regional Office on a doily basis until SSO ac n be stopped.
Per G.S. 143-215.1C(b), trio rosponsibte 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-wrf lrre-prscharge 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 denlonsfrdt a :
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 Permittoe
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 nt 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.
Page
CS-SSO Form
1
17/2 d 0170929912L :Ol
6S2261L172L S>li'10M SI1Bfid 1N0W188:W0i'ld 82:SO BT02-62-Nflf

City of Belmont
Distribution & Collections
14.01 East Catawba Street
Belmont, NC 28012
Pliane: 704-901-2073
FACSIMILE TRANSMITTAL
To: Lonnie Schneider
Fax #: [phone]
From: Danny Whisnant
Fax #: [phone]
Pages: 4
Date: June 29, 2010
Re: SSO
• If you tin not rereive all pages indicated, please call us at [phone]
t/T'd 01709299170L:01 6S22617L170L S71K1M OI19fId 1NOW108:14OaId L :80 OT02-62-Nil!'

Roots
Do you h0va an active root control program on the line / area In question? YmCI Na ® NA D NE
Describe r,
Hav4Ctga ng and inspections
1C��1�r�. ? A c 9Ue.'k-ee) / y bciSi',
Q �.tna, �
ever been increased at this location bocauso or roots? I ! YoC No 0 NAO NE
Explain:
Lk t ck okrc ors c. b?ejcossI;S
What corrective actions have been accomplished at the SSO location (and surrounding system if
associated with the SSQ)?
What corrective actions are planned at the SSO location to reduce root intrusion?
fdok k;11cc. 4"0 b0.1
Has the/line been smoke tested or videoed within the past year?
V t�c% SC wC 44, c. SS
If Yes, when?
Comments;
' 0 R vtA-c, +r'v c i'n
±t, Gleam 41-e ��n@
e0 NQ Q NAO NE
CS-SSO Form
Page
17/2'd 0t09299t,0L:Ol EL-2E617'2_17a_ SNelOM 9I18fld 'NOW188:WOcid 82:80 OT02-62-NNf

astern Visitation
ARC
Backup
Name:
Cert#
Date visited;
Time visited:
How was the S$O remediated (i.e. Stopped and cleaned u0)7
LA.) r
0
CT /-
lJ Yes
Yes
rrn y /c)4L n0 r,1
`,7/[a
Asa representative for the responsible p$rty, I certify that the informs (ion contained In this report Is true and accurate to
The es o my now a get.
Person submitting Claim;
Signature:
"If', ;r" a 7L.
Telephone Number 7 /-9 / -,_pc
Any additional information desired to be submitted should be sent' . the -appropriate Division Regional Office within five days of first
knowledge of the $SO with reference to the Incident number (the 1 cident number is only generated when electronic entry of this
(vim is completed, If used).
Date; e4 -07 9 /:
rile: i071in/Cc4//rey46+f S 14/.IrAttr/.1
C$-SSO Form
Page 15
17ib'd
01709299t'0)_:01
6S226i7L17.0L SNNOM 9I18fld 1NOW788:14OJd 85:80 aT02-62-Nflf

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#��
Incident Number from BIMS %o (CM 2D's?
Incident Reviewed (Date):
Incident Action Taken:
BPJ
NOV-2010-DV
Spill Date >'� Time 61.6D a/ prri
Reported Date 771/Time U �� am/
Reported To SWP Staff.ofaff
Reported By • . �A
Address of Spill (0•S`
• :County` ��so,�i•'
Cr AF
• City
Cause .of Spill p CF` •N `M
Total Estimated
ed Gallons On Est. Gal to Stream a o • . -
3
Stream �v. `4oct2,� Fish KiII: Yes Number " Species• _
Non Required Information.:and other comments relating to SSO incident:
. Response Time • minutes Zone Map Quad•

Permit# ..
WQCS00253
WQCS00196
WQCS00233
Owner and Facility Name
Bradfield Farms Water Company CS
Carolina Water Service Cabarrus Woods CS
Carolina Water Service Hemby Acres CS
WQCS00001 Charlotte -Mecklenburg CS
WQCS00016 City of Albemarle CS -
WQCS00046 City of Belmont CS
WQCS00107 • Cily of Bessemer City CS
WQCS00089 Cily of Cherryville CS. •
WQCS00221 Cily of Claremont CS
WQCS00326
WQCS00088
WQCS00017
WQCS00020
WQCS00327
WQCS00036
WQCS00040
. WOCS00164
WQCS00026
• WQCS00059
WOCS00044
WQCS00019
WQCS00037
WQCS00030
WQCS00149
City of Concord CS
City of Conover CS
Cily of Gastonia CS •
City of Hickory CS •
City of Kannapolis CS
City of Kings Mountain CS
City of Lincolnlon CS •
City of Lowell CS
City of Monroe CS
'City of Mount Holly CS
...City of Newton CS
•City of Salisbury CS
City of Shelby CS
Cily of Statesville CS
East Lincoln CS
Permit #
WQCS00171
WOCS00322
WQCS00222
WQCS00341
Owner and Facility Name •
Greater Badin CS
Aqua Country Woods East CS
Town.of Boiling Springs CS
Town of China Grove CS
WQCS00231 :Town.o( Cleveland CS
WQCS00058 Town of Gramerion CS
• WQCS00165 Town of Dallas CS
• WQCS00342 • Town of E. Spencer CS
WQCS00328 Town of Harrisburg CS
'WQCS00343 Town of Landis CS
WQCS00310 Town of Longview CS
. WQCS00120 Town of Maiden CS
WQCS00344. Town of MarshVille.CS
WQCSb0043 Town of Mooresville CS
WQCS00125 Town of MI Pleasant CS.
• WOCS00153 Town of Norwood CS
W.QCS00190 Town o(Oakboro CS •
WQCS00325 Town of Stanfield CS
•WQCS00180 Town of Stanley CS
- W.QCS00135 Town o(Taylorsville CS
WQCS.0025B Town of Troutman CS
WQCS00345 Town of Wingate CS
•WQCS00054 Union County CS
WQCS00009 . WSA Cabarrus Co. CS
•
Deemed Permitted
Permit
WOCSD0130
WQCSD0114
WQCS00057
WQCS00117
WQCSDO2S7
WQCSD0116
WQCSD0101
. WQCSD0095
W QCS D0098
WQCSDD105
WQCSD0107
WQCSDO099
WQCSD0258
WQCSDD112
WQCSDO104
WQCSDO102
.Owner and Facility Name .
Brooks Food Group -Brooks Food Group
Charlotte Mecklenburg Schools.- Misc Lalerals
City of High Shoals CS • . •
Duke Energy Marshall Steam Station
Fallslon
• Goose Creek Utilities Fairfield Plantation WWTP
Harborside Dev LLC-Midtown T CS •.
Kennedy Dev. Group LLC-Boardwalk Villas CS •
Kennerly Dev, Group LLC-Kings Point CS
Kennerly Dev. Group LLC-Moon Bay Condos CS
Kennerly Dev, Group LLC-Schooner Bay CS
Kennerly Dev. Group LLC-Spinnaker Point CS
Kingstown
Lake Norman -South Point CS..
Lake Norman -Villas S Harbour CS
Lake Norman -Vineyard PI Resort CS
Permit# Owner and Facility Name
WOCSD0064 Lincoln County CS
' WQCSDOD97 Martin Dev Gp-N Point & Portside CS
• WQCSD0120 Martin Marietta Mallard Creek
WQCSD0019 Town of Richfield CS
WQCSD0024 Town of Grover CS .
WQCSDOD38 Town of McAdenville CS
WQCSD0002 Town of Ranlo CS
WQCSD0049 Town of Spencer Mountain CS
W0CSD0252 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:
4
Taken by:
W Shadden
Reported by:
Sandra Craft
County:
Gaston
Street Address:
105 Hugh Street, Bellmont NC
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
NCEM Edited:
Yes
Date/Time Reported:
07/10/2010 18:45:18
Agency:
Bellmont Utilities
City:
Bellmont
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:
Include in Report:
Yes
Date/Time Occurred:
07/10/2010 09:00:18
Phone:
704-825-3791
Area:
13
Zip Code:
HazMat Mode:
Non-FNF Event Type:
WMD Event Type:
Event Description:
Local Utility reported a 3600 gallon sewer spill which occurred due to a force main break. The spill
entered an unknown branch to the South Fork River. No public drinking water sources affected and
no fish kill reported. Cleanup consisted of the application of lime to the affected area.
Filename:
Deaths:
0
Responsible Party:
Injuries:
0
Evacuation:
0
Responsible Party Phone:
Point of Contact: Point of Contact Phone:
Latitude:
35.23047
RRT Request:
RRT Approved:
Longitude:
81.045844
RRT Team
Radius:
0
RRT Mission
https://www.ncsparta.net/eoc7/boards/board. aspx?tableid=275&viewid=1011 &label=EM-... 7/12/2010

City of Belmont
Distribution on & Collections
1401 East Catawba Street
Ikirnam, NC 28012
Phone: [phone] Fax: [phone]
FACSIMILE TRANSMITTAL
f
To* Lonnie Schneider
Fax #: [phone]
from: Danny Whisnant
Phone #: [phone]
Pages: 5
Date: July 12, 2010
Re: SSO
• If you do not receive all pages indicated, please call us at [phone]
Sr I ' d 0b09299170L :01 6SE267L'OL S>NOM 9I18nd 1NOW138 : WOdd 9b : ti ti OT 2-21-nnr

Form CS-SSO
Collection System Sanitary Sewer Overflow Repotting Form
V 112009 PART 1
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. �liv- ...' .K (WOCS# if active, otherwise use WOCSD#)
Facility: COfift v/;WAS Sti.0-keif? 1 Incident #
owner: C4) el .gr-/..41.4 ' f Region: ,.
City: IFe/r> ri /1- County: Gas-lon
Source of SSO (check applicable) : fa Sanitary Sewer 0 Pump Station / Lift Station
SPECIFIC location of the SSO (be consistent in description from pest.reep�orts or documentation - Le, Pump Station 6,
Manhole et Weston& Stagg Street. etc.): Ao_r 6,- A "'�! '
Manhole#_ A/%/t
Latitude (degrees/minute/second): 044/. l2' Longttude(degrees/minute/second): - - 4/4
Incident Started Dt a• C-`!""Pelt/Q Time' .-,'��61°"t Incident End Dt: 617`/e)6'5 Time:�61°2-:°e/0"
(mm•dd-yyyy) hh:mm ANT/PM (mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: 0a gallons Estimated Duration (Round to nearest hour): kr5 Al-
Describe how the volume was determined; 42/59/
Weather conditions during SSO event 6"-edim .-
Did SSO reach surface waters? P2 Yes ❑ No0� e
Unknown Volume roeching surface waters (gallons): JO6" J/4A •
v
surface water name: 'ib , n b/ r,ic- /. 71D . j4A4!,6 ie•r-
Did the SSO result in a fish kill? 0 YesialloO Unknown if Yes, what is the estimated number of fish killed? SPECIFIC cause(s) of the SSO:
Q Severe Natural Condition 0 Graaso 0 Roots
0 Inflow and infiltration 0 Pump Station Equipment Failure 0 Power outage
❑ Vandalism ❑ Debris in line 0 Other (Please explain in Part lt)
® Pipe Failure (Break)
24-hour verbal notification (name of peroon contacted)
web S/,c ,..)der,
t....,t
ovv0 Emergency Mgmt Date (mm-dd-yyyy): 07 /a -tea Time (nh:mm AM/PM)- Ir5'S"
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO Can be stopped.
Per 0 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 an print and electronic news media providing general
coverage in the countyWhere 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 re arenced statute tor 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 feasibly afternatives 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 111S COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form Page
rK - 044-_ C4,to3O`'O
Sf2 ' d Ot'09€99b0L : Ol 6S22617i170L S)t OM OIl8nd 1N0W-138 : W0W 9b : T T OT02-2T -1nf

Pipe Failure (Break)
Pipe size (indigos)
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?
Last inspection date and findings
7- 9 --?4'o ' 7J 2 e-' of
If a force main then,
Was the break on the force main verltical?
Was the break on the Forco 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 alr-release valve to determine of operable?
When was the Iant matntanace of the air release performed?
If gravity sewer then,
Does the line receive flow from a force meln immedlotely upstream of the failed section of pipe?
If yes, whet mr5a9ures are taken to control the hydrogen sulfide production?
a Y
A,
iv/0
a©NZNE
Y4JJ No ��.J NAO NE
0Yea No❑NADNE
eUNo0NA®NtE
rife NoQIs/AO NE
Y
:11/
o lD NAQ NE
o❑NAONE
Al4
❑YeE0 NoDNADNE
When wee the line last inspected Or videoed?
CS-SSC7 Form Page 13
S/S • d 0t709299170L : Ol 6S22617L17.0L S)IZIOM OIl8nd INOW188 : NOaId Ltb : T T etie2-2T -nnr

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?
If temporary, when is the permanent repair planned?
Have there been other failures of this line in the past five years?
If so. then.describe
LJ Y
CS-SSO Form
Page '14
SA7'd 0t709299t70L:01 6S226f7LbJL SNelOM 9ln8nd 1N0W188:WOdd 2_7:TT OT02-aT-1nr

System Visitation
ORC
Stickup
Name.
Ce#
Date visited_
Time visited:
CilYea
0 YaS
4.r, 60010.5 her
Fix Vff
'1-I0-- rp
HOW was the SSO remediated (i.e_ Stopped andcleanedup)?
Fife ta.1a-.� Pe po e c . (1\c arc c . G- i m.c'
• As a representative for the responsible party, 1 certify that the information conteinod in this report is true and accurate to
the'best orrny knowledge.
Person submitting claim:
Signature:
tJ i'S v�t7� .vti -4
02A7
Date: %'(
Title: 0rsn0lf/A0,4/tt_ .4";14, 41 j1
a/Aie/4MS Rack up/0 rC..
Telephone Number 76 y / d - o2U
Any additional information desired to be submitted should be sent to the appropriate Division Regional me within five days of first
knowledge of the SSO with reference to the incident number (the incident number is only gonareted when electronic entry of this
form is completed, if used).
NNW
CS-SSO Form Page 15
S/€ ' d 01709299t70L :01 6S226i7L170L S>IWM 9I18nd 1N0W198 : Wa1d Lt7 : T 10T02-21-lnr

Collection System. SSO 24-Hour Notification
Collection System: Number and N.ame VVQCS# blc4(.:i •
Incident Number from BIMS oiDo . _(( c2
•
incident Reviewed (Date): :.
Incident Action Taken: BPJ•
NOV-2010-DV •
Spill Date • • • . 0
Reported. Date. ••
Reported To SWP Staff,or.M-staff
'•..Reported By
Address of Spill
• :County
LS
• Phone
• C ityi •
Cause •of Spill 6Av
•
•. .. 12�(•
Total Estimated Gallons
Stream L • Fish Kill: Yes
Est.•.Gal to Stream • Z Z • •
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 Waler Company CS
WQCS00196 Carolina Water Service Cabarrus Woods CS
WQCS00233 Carolina Waler•Service HembyAcres CS
WQCS00001 Charlohe-Mecklenburg CS •
WQCS00016 Cily of Albemarle CS " •
WQCS00046 Cily of Belmont CS
WQCS00107 Cily of Bessemer Cily CS
WQCS00089 Cily of Cherryville CS.
WQCS00221 Cily of Claremont 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
WOCS00036 City of K::.ys Mountain CS
WOCSD0040 City of, Lincolnlon CS •
.WOCS00164 Cily of Lowell CS ' •
WQCS000?6 ' City of Monroe CS '
WQCSOD059 'City of Mount Holly CS
W0CS00044 City of Newton CS . •
WQCS00019 . .City of Salishury CS
WOCS00037 Cily of Shelby CS
WQCS00030 City of Statesville CS
WQCS00149 East Lincoln CS
•
•
•
•
Permit# Owner and Facility Name
WQCSDO171 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
WQCS00058 Town of Cramerton CS
W'QCS00165 Town of Dallas CS
• WQCS09242 Town of E.-Spencer CS
. WQCS00328 Town of Harrisburg CS
'WQCS0O343 Town of Landis CS
WQCS00310 Town of Longview CS
.'WQCS00i20 Town of Maiden CS
WQCS00344 Town of Marshville•CS
• WQCS00043 Town of Mooresville CS
WOCS00125 Town of MI Pleasant CS,
•
WOCS00153 Town of Norwood CS
WQCS00190 Town of 0akbbro CS •
WQCS00325 Town of Stanfield CS
• WOCS00180 Town of Stanley CS
WQCS00135 Town ofTaylorsville CS
WOCS0025B Town of Troutman CS
WQCSOD345 Town o(Wingale CS
'WQCS00054 Union County CS
WOCS00009 . WSA Cabarrus Co. CS
Deemed Permitted
Permit# .Owner and Facility Name
WOCS00130 Brooks Food Group -Brooks Food Group •
WQCSD0114 Charlotte Mecklenburg Schools Misc Laterals
WQCSD0057 City of High Shoals CS .
WQCSD0117 Duke Energy Marshaal Steam Station
WQCSD0257 Fallslon •• :
WOCSD0116 Goose Creek Utilities Fairfield Plantation T P
WQCSD01O1 Harborside Dev LLC-Midtown T CS •
WQCSD0095 Kennedy Dev. Group LLC-BoardwalkViltas CS
WQCSD0096 Kennerly Dev, Group LLC-Kings Point CS
WOCSD01O5 Kennerly Dev. Group LLC-Moon Bay Condos CS
WQCSD0107 Kennerly Dev. Group LLC-Schooner Bay CS
WQCSD0099 Kenneriy Dev. Group LLC-Spinnaker Point CS
WQCSD025B Kingstown
WQCSD0112 Lake Norman -South Point CS.'
1NQCSD0104 Lake Norman -Villas S Harbour CS
WQCSDO102 Lake Norman -Vineyard Pl Resort CS
Permit # Owner and Facility Name
WQCSD0064 Lincoln County CS .
WQCSDOD97 MarlinDev Gp-N Point & Poriside CS
WQCSD0120 Martin Marietta Mallard Creek •
WQCSD0019 Town of Richfield CS
WQCSD0024 Town of Grover CS
WQCSD003B Town of McAdenville CS
WQCSD0002 Town of Ranlo CS
WQCSDOO49 Town of Spencer Mountain CS
WOCSDO252 All spills which do not have a permit •.
number assigned
•

tt
RUG-24-2010 11:09 FROM:BELMONT PUBLIC WORKS 7047493359 TO:7046636040 P.2/4
(e• G 3 < t7'-#•c,
Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
V 112009 PART I
This form shall be submitted to the appropriate DWQ Regional Office within five days of the first knowledge of
- the sanitary sewer overflow (S$C).
Permit Number: CS 4,4 W l ^D Zt
{WAGS# ifW
active, otherwise us®QCSD#) W _l` )
Facility: r irL7 ra-( Af/�rn.r I- 6;VietAn' hs- cycYrM Incident #
Owner /"r 2/5 o,e . i,*,Drt'� Region:
City: /7/-/fin 7i" [ County- (" it7 ft
Source of SSO (check applicable)) : ICf. Sanitary Sewer 0 Pump Station / Lift Station
SPECIFIC location of the SSO (be consistent in description from past/reports or documentation - i.e. Pump Station B,
Manhole et Westall & Bragg Street, etc.) : /I/ 6le wn4 .T
Manhole# N/,¢
Latitude (degrees/minute/second): "4""/-#.9 Longitude(degrees/minute/second)- - .4./f//
Incident Started Ot: 67--2Y-070/d Time: 9'4961 Oriel Incident End 1st: 67- 2a/4 Time: 7.42 "l"
(mm-dd-yyyy) hh:mm AM/PM (mm-dd-yyyy) nh:mm AM/PM
Estimated volume Of the SSO: '' gallons
Estimated Duration (Round to nearest hour): /---
Describe how the volume was determined: VyFl" ..
Weather conditions during SSO event: RQrf/rr Cf41-1/4,
Did SSG reach surface waters1 ® Yes 0 No0 Unknown Volume reaching surface waters (gallons): rie/
Surface water name: eirrrierrrrr� t . ?J A r4•' Wr/
Did the S$0 result in a fish kill'/ 0 Yes (3 No0 Unknown 1f Yes, what is the estimated number of fish klIiod?_...,....
SPECIFIC cause(s) of the SSD:
❑ Severe Natural Condition 0 Grease 0 Roots
❑ Inflow and Infiltration 0 Pump Station Equipment Failure 0 Power outage
0 Vandalism ❑ Debris in line 0 Other (Please explain In Part II)
0 Pipe Failure (Break)
24-hour verbal notification (name of person Contacted). 4j!<. �ScArt ei rfr-
DWQ Cl Emergency Mgmt. Date (rnrn-did-yyyy)
Time (hh:mm AM/PM)-
If en SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Par t3.$. 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 44-hours of first knowledge to all print and electronic news media providing general
coverage in the county-WhiFErlhirilltscharge 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.
TheDirector, Division of Wator Quality, may take enforcement action for SSOs that aro 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 Permittoo
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 Page 1

AUG-24-2010 11:09 FROM:BELMONT PUBLIC WORKS 7047493359 TO:7046636040 P.1/4
City of Belmont
Distribution Sr Collections
1401 East Catawba Street
Belmont, NC 28012
Phone: 704-90 i-2d73 Fax: [phone]
FACSIMILE TRANSMITTAL
To: Lonnie Schneider
Fax #: [phone]
From: Danny Whisnant
Pages: 4
Re: SSO
Phone #: [phone]
Date: August 24, 2010
IP you do not receive all pages indicated, please cal] us at (704001-2073

w
RUG-24-2010 11:10 FROM:BELMONT PUBLIC WORKS 7047493359 TO:7046636040 P.3/4
GreaselOocumentation such as cleaning, inspections, enforcement actions, past overflow reports,
educational material and distribution date, etc, should-Ee available upon request.)
___ a
Do you have an enforceable grease ordinance that requires new or retrofit of grease traps/interceptors? 3sve0 No © NAE NE
When was the last time this specific line (or wet welt) was cleaned?
Have there been recent inspections andior enforcement aetions taken on nearby restaurants or other © Yei No © NAD NE
nonresidential grease contributors?
Explain.
Have there been other SSOs or blockages in this area that were also caused by grease? 0 Y ZI No Q NAO NE
\Men?
If yes, describe them:
Have cleaning and inspections aver been increased at thls location? • Yets No ❑ NAO NE
Explain,
Have educational materials about grease boon distributed in the pest?
When?
and to whom?
Explain?
a r
If the SSA occurred at a pump station, when was the wet wall an pumps last checked for grease
accumulation?
Were the floats clean?
Comments:
YgFEJ NO Q NAD NE
-7-7.4ie<c ar �cct
All re.r aco,. i<
�Y�tQ NOQNAD NE
CS-SSO Form
Page 4

RUG-24-2010 11:10 FROM:BELMONT PUBLIC WORKS 7047493359 TO:7046636040 P.4/4
System Visitation
ORC
Yes
Backup igvas
Name: .Nn17 Ca-Ji,rsr�-u��
Certt# 9,Yg7 r
Date visited: a `-i )0,0
Time visited: / '
How was the SSO remedieted (i.e. Stopped and Cleaned up)?
E' ertvarx i r1 avt d arc¢,_
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: lDco.",,,
Signature:
ir65cs.iri{
Date:
Title: f-'-b`11'e►'�i S�6•x'� SvF'crr.cdG'rt7'
—Dace . up Q,ec
Telephone Number: %O'-/ 96 i aD 73
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 thls
form is complotod, if used)-
CS-SSO Form Page 15

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#( .Y1 C.
Incident Number from DIMS 20( I c7l-{
Incident Reviewed (Date):
Incident Action Taken: BPJ
NOV-2011-DV
12 02 22 6 8 0 0 0 222222616062211.211L 9 6@ o e e o H® 0 C 6! 8 N D B d C R C H[ C B L B G Y H 2 H Y 0 6 C 2 R B B E E 6 0 6 0
Spill Date
Reported Date
Reported To SWP ,Staff or EM Staff
Time (f' 14v am/eir
Time 336 am/
LS
Reported By iR,tim 5 Phone
Address of Spill —71 -3 C/1- SC)eAd
County
City
Cause of Spill e(4.1;
Total Estimated Gallons Z U Est. Gal to Stream cZ 0
Stream
Fish Kill: Yes EP Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# 10A, 000%
Incident Number from BIMS 2)0(0 0 7-1-1
Incident Reviewed (Date):
Incident Action Taken: BPJ
NOV-2010-DV CenC--
Spill Date / v(r 7 Time i O am/
Reported Date (c)((2. Time S gS---Qs1
I pm
Reported To SWP Staff or EM Staff L $
,r..;
Reported By t y Phone
Address of Spill Q O L)-e, S
County City ‘5.4110,i (I --
Cause of Spill Jr, s
Total Estimated Gallons L G v Est. Gal to Stream ?CD
Stream iliky Fish Kill: Yes( Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

OCT-18-2010 11:12 FROM:BELMONT PUBLIC WORKS 7047493359
TO:7046636040 P.2/4
Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
Thls form shall be submitted to the appropriate DWQ Regional Office within five days
the sanitary sewer overflow ($SO),
Permit Number:
e3 coy (WQCS# if active, otherwise use WOCSD/f)
Facility: else! eF 8e1 {- t�tlitCi rbrt S JySitree
Owner CI 4f VC/wooed'
City: e1+_•a h f
Source of SSO (check applicable) :
SPECIFIC location of the SSO (be consistent in description from
Manhole at Westall 8 Bragg Street, etc.)
Manhole# p¢
Latitude (degrees/minute/second):
Incident Started Dt:
(mm-rid-yyyy) q
Estimated volume of the SSO: . <� gallons
Describe how the volume was determined: 75pM
14 Sanitary Sewer ❑ Pump Station / Lift Station
past reports or documentation • i.e. Pump Station 6, .
PART I
of the first knowledge of
Incident # Z of OO .°1
fttJ/ Itx
/O./7-•26/0
Time:. //-© fi71
hh:mm AM/PM
Weather conditions during SSO event: `�r'w`9
Did SSO reach surface waters? `r Yes ❑ No❑ Unknown
surface water name: ', tbry Crec
Did the SSO result in a fish kill? ❑ Yes E Not: Unknown If Yes, what is the estimated number of fish kilted?
SPECIFIC couse(s) of the SSO:
Region;
County: 61654ea�
longitude(deg re es/m1n uteJs a cond):
Incident End Dt:. /63-t 7 p/o
(ant-dd.> yy)
Estimated Duration (Round to nearest hour):
A—//eift
Timer
1)e PI"!
hh:mm AM/PM
Volume reaching surface waters (gallons):
t_..t Severe Natural Condition
O Inflow and Infiltration
❑ Vandalism
❑ Pipe Failure (Break)
24•hour verbal notification (name of person contacted
EgDWO U Emergency Mgmt.
❑ Grease
❑ Pump Station
!�1 Debris in line
0
Equipment Pallure ❑
Roots
Power outage
Othdr (Please explain in Part It)
Ler S2.r, deft_
Date (mm-dd-yyyy): /6"er'.2/o Time (hh:mm AM/PM):''; V ,tr'�=
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 40..haurs of first knowledge to all print and electronic news media providing general
coverage In the county`Wh Seem TItscharge 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 Duality, may take enforcement action for SSOs lbet are required to be reported to Division unless it
is emonsrae a:
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 exorcise of reasonable control,
Part iI must be completed to provide a justification claim for either of the above situations. This information will be Iho 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 REQUtRED AT THE CND OF THIS FORM.
CS-SSO Form — Page
1

OCT-18-2010 11:12 FROM:BELMONT PUBLIC WORKS 7047493359 T0:7046636040 P.1/4
City of Belmont
Distribution & Collections
140.i..East Catawba Str ct
Belmont, NC 28012
Phone: [phone] Fax; 704-749-3359
FACSIMILE TRANSMITTAL
To: Lonnie
Fax #: [phone]
From: Danny Whisnant
Phone #: [phone]
Pages: 4 including cover sheet
Date: 10/18/2010
Re: SSO
• if you do not receive all pages indicated, please call us at [phone]

OCT-18-2010 11:12 FROM:BELMONT PUBLIC WORKS 7047493359 T0:7046636040 P.3/4
Debris in Tine (Rocks, sticks. rags and other items not allowed in the collection system, etc.)
What type of debris has been found in the line?
fe
Suspected cause or source of debris.
Are manholes in the area secure and Intact?
When was the area last checked/cleaned?
Ye0No0NAG NE
Have cleaning and inspections ever been increased at this location due to previous problems with debris? try Yee No 0 NAO NE
Explain:
in/pe.c+i
Are appropriate edueatianal materials being developed and distributed to prevent future simIfar Yo7INO 0 NA NE
occurrences?
Comments:
Suitt be 5enecy evf a le er .12) cy us4.6 rs
CS-SSO form _..
Page 11

OCT-18-2010 11:13 FROM:BELMONT PUBLIC WORKS 7047493359
TO:7046636040 P.4/4
System Visitation
ORC
i ackup
Name:
Cart#
Date visited:
Time visited:
❑ Yes
BYes
RP7S-t
lc- 19- Ja
Mow was the--SISP remediated (i.e. Stopped and cleaned up)?
` c tie- 4 {vv k i d1 (d co c
As a representative for the responsible party, I certify that the inform$ tion contained in this report is true and accurate to
the best of my know e ge.
Person submitting claim: -ck.,.f
Signature: (4.v_
Telephone Number:
Data: 14 -? P Pc5 0
`title: fArfet - Seurr e ���es`rk �rrc a rr•T
CO f r0Uf'i 4✓l, bq aJrM/4,-C
Any additional information Cesired to be submitted should be Sent' • the appropriate Division Regional Office within five days of first
knowledge of the SSO with reference to the incident number (the 1 cident number is only generated when electronic entry of this
form is completed, if used).
CS-$S0 Form Page 15

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# rU (Yee
Incident Number from BIMS it) 03905-
Incident Reviewed (Date):
Incident Action Taken: BPJ
1,--7/'` ` NOV-2010-DV , I
e-L
Spill Date // a(/b
Reported Date //4//D
Reported To SWP Staff or EM Staff
Time /a. T5 �a
Time 3 ;(0 am/
•&5--
Reported By QOr\IAV W VU( ` C Phone
Address of Spill
County
rh4 ed2Q.2 Meced2 6,(S
Cause of Spill
Total Estimated Gallons
Stream
City
Fish Kill: Y
£n.Q-) (6kee4
Est. Gal to Stream -
Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

NOU-30-2010 15:04 FROM:BELMONT PUBLIC WORKS 7047493359 T0:7046636040 P.2/5
Form CS-SSO
Colloction System Sanitary Sewer Overflow Reporting Form
This form shall be submitted to the appropriate CWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number . WQCS00046
1 aClljty City of Boirn0nt C6110di0ns Syslom
PART I
(WQCS# if active, otherwise use treatment plant NG/WQ#)20` tJ Z Za�
Incident # `7
City of Belmont
Owner: Region:
City. e gln,unf County.
`o'
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 Wostall 8, Bragg Street, etc) 4080 Dello Meade Qirclo Manhole at Lift Station
Latitude (degrees/minute/second). N/A Longitude(degreeslminute/second) N/A
Incident Started Dt• 11-29-2010 Tlme 10:45 am Incident End Dt 11-29-2010 Tlme 11:42 am
(mm-dd-yyyy) hh.mm AM/PM (rnrn-dd-yyyy) hh.mm AM/PM
Estimated volume of the SSC: 456 gallons Estimated Duration (Round to nearest hour)'
Describe how the volume was determined. 8 gem
Weather conditions during SSO event Partly cloudy m
Did SSO reach surface waters'? Q Yes ❑ No ❑ Unknown Volume reaching surface waters (gallons) 456
Surface water name: unnamed stream feeding to South Fork
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 LI Grease ❑ Roots
❑ Inflow and Infiltration ❑ Pump Station Equipment Failure ❑ Power outage
❑ Vandalism © Debris in line ❑ Other (Please explain in Part II)
Barbera Stifford
Immediate 24-hour verbal notification reported to:
DWQ ❑ Emergency Mgmt.
Date (mm-dd-yyyy): 11.29-2010
Time (hh:mm AM/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 press release within 48-hours of rirst 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 Quay, 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 Psrmittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control
Part II must bo completed to provide a justification claim for either of the above situations. This information will bo the basis
for the determination of any enforcement action. Therefore, it is important to be as complete es possible.
WHETHER OR NOT PART 11 IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM,
CS-SSO Form October 9, 2003
Page 1

NOV-30-2010 15:04 FROM:BELMONT PUBLIC WORKS 7047493359 TO:7046636040 P.1/5
City of Belmont
Distribution & Collections
1401 East Catawba Street
Belmont, NC 28012
Pbon.c: 704-901-2073 Fax: [phone]
FACSIMILE TRANSMITTAL
To: Lonnie
Fax*: 704-663-6040
From: Danny Whisnant
Phone #: [phone]
Pages: 5 including cover sheet
Date: 11/29/201.0
Re: SSO
• If you do not receive all pages indicated, please call us at [phone]

ti
NOV-30-2010 15:05 FROM:BELMONT PUBLIC WORKS 7047493359 T0:7046636040 P.3/5
Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
PART I I
ANSWER THE FOLLOWING QUESTIONS FOR EACH ELATED CAUSE CHECKED IN PART I OF THIS FORM
AND INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SLCTIONS 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 SUeMITTi ID 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 avant?
Comments:
Grease Documentation such as cleaning, inspections, enforcement
actions, past overflow reports, educational material and distribution date,
etc, should be available upon request.)
Wien was the last timo this specific line (or wet well) was cleaned?
4o you have an enforceable grease ordinance that requires new or retrofit of groaso traps/interceptors?
Have there been recent inspections and/or enforcement actions taken on nearby restaurants or other
nonresidential grease contributors?
Explain.
FOG Program
05-24-09
LYesu Nc,1,,,.1 NA ❑ NE
QYQF,LJ NQDNA DNE
Have there been other SSOs or blockages in this aroa that were also caused by grease?
When?
If yes, describe them:
Soyw.e LOC.cr..4 a -
llYesEi NoDNAUNE
019
Have cleaning and inspections ever been increased al !his location?
Explain
e.das neW>y / ed
/re ij/e'n b . / Aosa/
�YesD No DNAL:NE
�e'.vt✓d t4r . dI' [].bauT1 et r.G✓Gs ."9..211s414)7
CS-SSO Form October 9, 2003 Page 2

NOV-30-2010 15:05 FROM:BELMONT PUBLIC WORKS 7047493359 TO:7046636040 P.4/5
Have educational materials about grease bean distributed in the past?
Whon'?
and to whom?
Explain?
Grease Gobbin Insert
CI Yen No DNA ONE
November's water bill
all customers
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.
Yen No O NA OW
Roots
Do you have an active root control program 7
Describe
Have cleaning and inspections ever been increased at this location because of roots?
Explain:
❑Yes0 No NAONE
OYs NoONAONE
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 or videoed within the past year?
If Yes, when?
Comments:
Iw1Yes0 NoONA NE
Inflow and Infiltration
Are you under en SOC (Special Order by Consent) or do you have a schedule in any permit that OYesO No DNA ONE
addresses 1J17
CS -$SO Form October 9, 2003
Page 3

NOV-30-2010 15:05 FROM:BELMONT PUBLIC WORKS 7047493359 T0:7046636040 P.5/5
Asa 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: Danny Whisnant
Signature:
Telephone Number. 704-901-2073
Title -
Date: 11-30-2010
Olatributlon - Colloctions Ouporfntondonl I pack up ORC
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 whon electronic entry of this form
is completed, if used).
CS-S$O Form October 9, 2003
Page 8

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# 0nL{
Incident Number from BIMS '2c' (Oct (2T?
Incident Reviewed (Date):
Incident Action Taken: .RPJ
NOV-2010-DV OLitI
Spill Date l ( 7.
Reported Date
1►(r2
Time (-{ t-(Z am/ ey
Time
3s, ED' II
Reported To SWP Staff or EM Staff LS
Reported By gAN.m.) y Phone
Address of Spill .-cc_c 5+
County City (3elM0.-'
Cause of Spill Q.s-S (`Jan S
Total Estimated Gallons Est. Gal to Stream
Stream 93etigc
S
Fish Kill: Yes No Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

NO)-15-2010 14:15 FROM:BELMONT PUBLIC WORKS 7047493359
TO:7046636040 P.2'5
Source of SSO (chock applicable): ®. Sanitary Sewer
Pump Station / Lift Station
SPawQIFIC location of the SSC (be consistent in description from past reports or documentation - i.e. Pump Station B,
Manhole at Westall & Bragg Street, etc) • —64
Manhole#
Forrn CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
PART
This form she!i be submitted to the appropriate DWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number; 14.1itC5Ock, 4/6p)
(WCtCS#11f active, olh®rwise use WQCSD#)
Facility:l r1r_.l .G`u//� Incfdent�S
Owner: .trj��* $''.%►+jai+ Region:
City: /I►1on g9
County: . 64s740>• .�...�.
Latitude (degrees/minute/second); .�1r Longitude(degreeslminute/second):
incident Started Dt: ,[f-11 ^.2 ld Time: ',PT incident End Dt: a//-11-4,0' 3 Tirhe• G' fS
(mm-dd-yyyy) hh:mrn AM/PM (mm.dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: gd D , -- — gallons Estimated Duration (Round to nearest hour)- - 46t'
Describe how the volume was determined; P1. `ft!k
Weather conditions during SSO event: C(CQ r'
Did $SC reach surface waters? 0 Yes (ENoD Unknown
Surface water name;
Did the SSO result in a fish kill? 0 Yes tgl N00 Unknown If Yes, what is the estimated number of fish kilted?
SPECIFIC cause(s) of the SSO:
❑ Severe Natural Condition
r❑�t Inflow and Infiltration
t❑ vandalism
Pipe Failure (Break)
24-hour verbal notification (name of person contacted)
1 DwQ © emergency Mgmt.
Greose 0 Roots
❑ Pump Station Equipment Failure ❑ Power Outage
Debris in line ❑ Other (Please explain in Patin)
7j
Volume reaching surface waters (geitons);
Date (mm•dd-yyyy)- f 1"I=2/Q
Time (hh:mm AM/PM)' 9.'3S
If an SSO is ongoing, Tease notify Regional Orrice on a daily basis until S50 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 iisuo a press release within 48-hours of first knowledge to all print and electronic news Media providing general
coverage in the countywn-gra-ttwcirfscharge 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 1 ivlslon within 30 days.
Refer to the reterenced statute for further detail,
The Director, Division of Water Quality, may lake enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated'I a
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 Permittoo
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part 1I must be completed to provide a justification Claim for either of the above situations. This information will be the basis
for tho 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 REOUtRED AT THE END OF THIS } t Rilrl.
CS-$SO Form Page 1

NOV-15-2010 14:15 FROM:BELMONT PUBLIC WORKS 7047493359 TO:7046636040 P.1/5
City of Belmont
Distribution & Collections
1,1,()1 East Catawba St�ccl
Belmont, NC 28012
Phone: [phone] Fax: [phone]
FACSIMILE TRANSMITTAL
To; Lonnie
Fax #: [phone]
From: Danny Whisnant
Phone #: [phone]
Pages: 5 including cover sheet
Date: 11/15/2010
Re: SSO
• If you do not receive all pages indicated, please call us at (704)901.-2073

NOV-15-2010 14:16 FROM:BELMONT PUBLIC WORKS 7047493359 T0:7046636040 P.3/5
Roots
Do you have an active root control program on the line / area in question?
Describe
YeiENo0NAQNE
Have cleaning and inspections ever been increased at this location because of roots?
Explain
No Ej NAD NE
What corrective actions have been accomplished at the SSCi location (and Surrounding system if
associated with the SSO)7
37 ...C2-4r
Whattccorrective actions are planned at the SSO location to reduce root intrusion?
Has the line been smoke tested or videoed within the past year?
it Yes, when?
Commonts:
0 YeZ No © NA❑ NE
CS-Sso Form
Page

NOV-15-2010 14:16 FROM:BELMONT PUBLIC WORKS 7047493359 TO:7046636040 P.4/5
A••
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?
Suspected cause or source of debris.
Nfr9-
Are manholes in the area secure and intact?
When was the area last checked/cleaned?
0Ye0 No0NAONE
Have cloening and inspections ever been increased at this location due to previous problems with debris? 0 Y
Explain:
0C3NADNE
Are appropriate educational materials being devolopod end distributed to prevent future similar Ye No 0 NA NE
occurrences?
Comments:
Set..ve r Ytin4i h
t i ' 3.4 Lt.?Pl° It
CS-SSO Form
Pagra 11

•.•4 Ar
NOV-15-2010 14:16 FROM:BELMONT PUBLIC WORKS 7047493359
TO:7046636040
P.5/5
System Visitation
ORC
Name;
Cerro!
Dale visited:
Time visited`
Yes
Backup
EYes
How was the SSO remediated (Le. Slopped and cleaned up)?
Mtn y b rs anjL
!!�/2-fa
Asa representative for the responsible party, I Certify that the ihfarmF lion contained in this report la true and accurate to
e Fororn now
Person submitting claim: ' .73. ny 6 is n4 n Date: t l — if ?o ! c
Signature:
Telephone Number: 75' — 'el /-c 1=37
Any additional Information desired lc by submitted should be sent , the appropriate Division Regional Office within five days of first
form is completed, if used).
knowledge of the SSO with reference to the incident number (the i cident number is only generated when electronic entry of this
CS-SSO Form
Title: hJQr f 5�• ��r �'erfie frC%yT'
Cciltt dh backut a.ee
Page 15

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# 000 14-(D
Incident Number from BIMS 20(00S S S Z'
Incident Reviewed (Date):
Incident Action Taken: BPJ
NOV-2011-DV
Spill Date (2t ( v( D Time 5 3 t am/ I
Reported Date 2((l Time IA ( am/ @ji i
Reported To SWP Staff orM taff S
Reported By
Address of Spill (0(. ' - — F
Phone
County City ("-
Cause of Spill f
Total Estimated Gallons
Est. Gal to Stream
Stream S9 Fish Kill: Yes umber Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

`j ' 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 12/18/2010 19:41:48, 12/18/2010 17:30:48
Reported by: Agency: Phone:
Sandra Craft Belmont Utilities 704-825-3791
County: City: Area:
Gaston Belmont 13
Street Address: Zip Code:
106 Main 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 reported that approximately 5 gallons of sewage spilled due to a clog of rags. Spill
started at 1730 hrs and ended at 1900 hrs. Approximately 2 gallons of spill entered a storm drain
with no water being affected. Clean up was done by applying absorbent pads and kitty litter.
Filename:
Deaths: . Injuries: Evacuation: Radius:
0 0 0 0
Responsible Party: Responsible Party Phone:
Point of Contact: Point of Contact Phone:
Latitude:
00.000000
RRT Request:
RRT Approved:
Longitude:
00.000000
RRT Team
RRT Mission
https://www.ncsparta.net/eoc7/boards/board.aspx?tableid=275 &viewid=1011 &label=EM... 12/20/2010

t
Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#
Incident Number from BIMS SS 55
Incident Reviewed (Date):
Incident Action Taken:
BPJ
/ 6l
NOV-20<<g-DV (rDq 1
Spill Date 1 7r 2--3 1 Tirrfe
1Z. 23.� 1 ° 1:3s�
Reported Date Time am/
Reported To SWP Staff or EM Staff
� �
Reported By �G N Jv`s I✓l�'j!11'J5 Phone qo
�q V 6, "j
`i
Address of Spill T / L. 612, PA ,2-LJ( 5--t,t9 Lbe---PIL
County City`� "k.U
Cause of Spill �� <-2A-vK--- fi,;(1(-2-- AA-i9A.) 0(2-- /41:4 t) 1 VO(ift
Total Estimated Gallons J Est. Gal to Stream
30 A \lii,
Stream Fish Kill: Yes No Number Species
Non Required Information and other comments relating to SSO incident:
Response time mimes Zone' Map Quad

Permit #
WQCS00253
WQCS00196
7 WQCS00233
WQCS00001
WQCS00016
\nIQCS00046
WQCS00107
WQCS00089
WQCS00221
WQCS00326
WQCS00088
WQCS00017
WQCS00020
WQCS00327
WQCS00036
WQCS00040
WQCS00164
WQCS0o026
WQCS00059
WQCS00044
WQCS00019
WQCS00037
WQCS00030
WQCS00149
Owner and Facility Name
Bradfield Farms Water Company CS
Carolina Water Service Cabarrus Woods CS
Carolina Water Service Hemby Acres CS
Charlotte -Mecklenburg CS
City of Albemarle CS
City of Belmont C.C..
City of Bessemer City CS
City of Cherryville CS
City of Claremont CS
City of Concord CS
City of Conover CS
City of Gastonia CS
City of Hickory CS
City of Kannapolis CS
City of Kings Mountain CS
City of Lincolnton CS
City of Lowell CS
City of Monroe CS
City of Mount Holly CS
City of Newton CS
City of Salisbury CS
City of Shelby CS
City of Statesville CS
East Lincoln CS'
Permit #
WQCS00171
WQCS00322
WQCS00222
WQCS00341
WQCS00231
,V V QCS00058
WQCS00165
WQCS00342
WQCS00328
WQCS00343
WQCS00310
WQCS00120
WQCS00344
WQCS00043
WQCS00125
WQCS00153
WQCS00190
WQCS00325
WQCS00180
WQCS00135
WQCS00258
WQCS00345
WQCS00054
WQCS00009
Owner and Facility Name
Greater Badin CS
Aqua Country Woods East CS
Town of Boiling Springs CS
Town of China Grove CS
Town of Cleveland CS
Town of CI a111ei Lv11 CS
Town of Dallas CS
Town of E. Spencer CS
Town of Harrisburg CS
Town of Landis CS
Town of Longview CS
Town of Maiden CS
Town of Marshville CS
Town of Mooresville CS
Town of Mt Pleasant CS
Town of Norwood CS
Town of Oakboro CS
Town of Stanfield CS
Town of Stanley CS
Town of Taylorsville CS
Town of Troutman CS
Town of Wingate CS
Union County CS
WSA Cabarrus Co. CS
Deemed Permitted
Permit #
WQCSD0130
WQCSD0114
WQCSD0057
WQCSD011•7
WQCSD0257
WQCSD0116
WQCSD0101
WQCSD0095
WQCSD009B
WQCSD0105
WQCSD0107
WQCSD0099
WQCSD0258
WQCSD0112
WQCSD0104
WQCSD0102
Owner and Facility Name
Brooks Food Group -Brooks Food Group •
Charlotte Mecklenburg Schools - Misc Laterals
City of High Shoals CS
Duke Energy Marshall Steam Station
Fallston
Goose Creek Utilities Fairfield Plantation WWTP
Harborside Dev LLC-Midtown T CS
Kennerly Dev. Group LLC-Boardwalk Villas CS
Kennerly Dev. Group LLC-Kings Point CS
Kennerly Dev. Group LLC-Moon Bay Condos CS
Kennerly Dev. Group LLC-Schooner Bay CS
Kennerly Dev. Group LLC-Spinnaker Point CS
Kingstown
Lake Norman -South Point CS
Lake Norman -Vitas S Harbour CS
Lake Norman -Vineyard Pt Resort CS
Permit #
WQCSD0064
WQCSD0097
WQCSD0120
WQCSD0019
WQCSD0024
WQCSD0038
WQCSD0002
WQCSDO945
Owner and Facility Name
Lincoln County CS
Martin Dev Gp-N Point & Portside CS
Martin Marietta Mallard Creek
Town of Richfield CS
Town of Grover CS
Town of McAdenville CS
Town of Ranlo CS
Town of Spencer Mountain CS
WQCSD0252 All spills which do not•have a permit
number assigned

DEC-28-2010 15:03 FROM:BELMONT PUBLIC WORKS 7047493359
TO:7046636040
P.2'4
Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form •
V 1/2009 PART
This form shall be submitted.to the appropriate OM Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number : (,> C S ape -1 (p, (WQCS# if active, otherwise use WQCSD#)
Facility: C14-1 c 4- '1 Y,A- CO(leC-l-leas-S-Few, Incident#
Owner. Cfs3 i?f . - J mcrt T' Region:
City' -13c.jw,C1n- - County.
Source of SSO (check applicable)!
SPECIFIC
Manhole at Westall & Sragg Street, etc ) -
Manhole#
N/44
Latitude (dogroos/minuto/second):
Incident Started Dt: 1a-a3-0b0 Time: 8; ,S3 o.y4A
(mm-od-yyyy) hn:mm AM/PM
Estimated volume of the SSO' - % fF 0 gallons
Describe how the volume was determined' gPm
Weather conditions during SSO event: cir (( +ti o d
Did SSO reach surface watery? ® Yes 0 NoUnknown
Surface water name- S+6 rrr, �r Ali n
sanitary Sewer ❑
Jou33S---
(Z,cks4r‘
Purnp Station / Lift Station
location of the SSO (be consistent in description from past.reports or documentation . i.e. Pump Station 6,
541fa Grct, 64-o n e C54•--cs. r
ILJJ�-
Did the SSO result in a fish kill?
SPECIFIC cause(s) bf the SSO:
❑ Severe Natural Condition❑r Grease
0 Inflow and Infiltration El Pump Station Equipment Failure
0 Vandalism 0 Debris in line
❑ Pipe Pailure (Sneak) i iF5
24-hour verbal notification (name of person contacted) ' nn - - San y c
r—
Longitude(degrees/minute/second)-
Incident End Dt 0-a3` 201c) Time: 31 a3
(mm-dd-yyyy) hh:mm AM/PM
j-)i/1
Estimated Duration (Round to nearest hour)'
Volume reaching surface waters (gallons):
© Yes calloa Unknown If Yes, what is the estimated number of fish killed?.
0 Roots
❑ Power outage
Other (Please explain in Part II)
1„ 1
[Zr DWQ El Emergency Mgmt. Date (mm-dd-yyyy)
Time (hh:mm AM/PM)' /0-'40 5
If an SSO is ongoing, please notify Regional Office on e daily basis until SSO Can be stopped.
Per G.S. 143-215.10(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
watery shall issue a press release within 4$-hours of first knowledge to all print and electronic news media providing general
coverage in the county wharo 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 SSQs 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 Dy factors beyond the reasonable control of the Pormittee
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 bo 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

DEC-26-2010 15:03 FROM:BELMONT PUBLIC WORKS 7047493559 TO:7046636040 P.1/4
City of Belmont
1 101 East. Catawba SL.rceL
Belrnola, NC 28012
Phone: [phone] Fax: [phone]
FACSIMILE TRANSMITTAL
To: Lonnie Schneider
Fax #: [phone]
From: Danny Whisnant
Pages: 4 including cover sheet
Re: SSO Report
Phone #: [phone]
Date: 12/28/2010

.� .
DEC-28-2010 15:04 FROM:BELMONT PUBLIC WORKS 7047493359 TO:7046636040 P.4/4
System Visitation
osc
Name:
Cert4
Backup
r�r7 4tJi4f <Srt a dit 71.
Date visited: /./ot 3/ 2c /
Time visited:
Yos
How was the SSO remediated (Le. Stopped and cle/a�ned up)?
c( Orr' rei{4Pvbju .
As a representative for the responsible party, 1 certify that the information contained in this report is true and accurate to
t1Ro'basf of my knowledge.
Person submitting claim rtr1.23101.
Signature:
Date: r /0-gb)010
Title: W S Suprin-�c'n.c/e'r/-
" c.k v p/o,•ec
Telephone Number: 7j 9-,ev .- e9O2S
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 generatod whon oloctronic entry of this
form is completed, if used).
CS-SSO Form Page 15

wJoA ()Ss -SD
// 7/7 .) o .a?vr>Ira)v_' 1...t0 .21.1vp 7)51)y
L/rr?O 7'v� 4/?1 1)- ' ✓q/ P.7p/svi /5-07
466 /
4/66/
:sluawwo3
3N Ob'N oN I—ee,l i
I c a 1 4 P 11 p q l pinoo wa oJd LOSS
ay1;o loedwi 0U1 uassa ue Q warn suol oe E m ' v�lecio� �(o el vwwl b ou Ig 41 jI
-a4/ 4 �f y 4-rq,.7117- of -t9sr.2,✓dwo /&
:uleldxe 'SBA dl
,w01go.rd out x, 01 algelleA sadinooa.i pug luawdlnbe aaenbaps edeM
do g✓.-, y air/v/l?� Jib.
:aguosed
(lsanbeJ uodn a)g2Iiene aq;Snw 'algeoHdde sE 1.1odaJ eoijod pue sa.lnlo!d) J21440
b/2'd Ob09299bOL:Ol ES2267Lb0L SNelOM Ol1aild 1NOW138:W0?a.d 170:ST 0T.02-B2-330

4 .
Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# C L4 to
Incident Number from BIMS 2,04001i9
Incident Reviewed (Date):
Incident Action Taken: BPJ
ZNOV-201 1-DV
0(4-7
Spill Date (13 (( Time (0 3(--( ar / pm
Reported Date Time Z- �l am/�i i
Reported To SWP Staff or EM Staff
LS
Reported By at.) Phone
Address of Spill Lr) (-/-5 - re-f(e)
County City
Cause of Spill
Total Estimated Gallons 21 5 2
Est. Gal to Stream 2- (SZ
Stream Fish Kill: Yes No Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

JAN-18-2011 10:54 FROM:BELMONT PUBLIC WORKS 7047493359 TO:7046636040 P.2/4
tr—
F� Ape
o Y
Forth CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
V 1 /2009 PART I
This form shall be submitted to the appropriate IDWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number : L4JQC5 Odd 4/en (WQCS# if active, otherwise use WQCSD#)
Facility: e;r1/' o/Zeioe' CQ(/(Ci,4,4_e ..eyfry Incident#
owner: ei%tj O'"-6.e)Iv%or4- Region: I
City• - —5c� uy,Q n 4- _ County- 540e''t
Source of $SO (check applicable) : 21 Sanitary Sewer ❑
Pump Station / Lift Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation - i.e. Pump Station 6,
Manhole at Westell & Bragg Street, etc.): .t9 474 a`P (-OA7 64 F-r" rYr // /¢vim
Manhole# 0A-719
Latitude (degrees/minute/second):
N1/4
Longitude(degreeslminute/second)- -. /
Incident Started Dt Of - f Time: / t7: 3`f 0-M Incident End Dt: - t3 "24' f f Time- 3'
(mm-dd-yyyy) hh:rnm AM/PM (mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO 2f Sa. gallons Estimated Duration (Round to nearest hour). .._ 05.
[Describe how the volume was determined' S),y'vt
Weather conditions during S$O event: ,5u., PI
Did SSO reach surface w ters? Yes 0 No❑ Unknown Volume reaching surface waters (gallons): a2/5
Surface water name: ibCk t i`c&tc- 1.
Did the SSO result In a fish kill? 0 Yes ►.1 NQ❑ Unknown If YeS, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
❑ Severe Natural Condition
❑ Inflow and Infiltration
❑1 Vandalism
u Pipe Failure (Break)
244--hour verbal notification (name of person contacted). hOn 5 1 it/C,'
iDWd ❑ Emergency Mgmt. Dote (mm-dd-yyyy). 61"f1` tot 1 Time (hh:mm AM/PM)- a-'
Grease ❑ Roots
❑ Pump Station Equipment Failure 0 Power outage
❑ Debris in line 0 Other (Please explain In Pert II)
it
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 dischargo of 1,000 gallons or more of untroated 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- wh8rErtheZtrscharge occurred. When 15,000 gallons or mere 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 ra r+tinced statute for runner detail.
The Director, Division of Wgtar Quality, may take enforcement action for SSQs 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 reosonabio control of tho Pormittoo
and/or owner, and the discharge could not have bean prevented by the exercise of reasonable control.
Part II must bo 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 SIGNATUR IS REQUIRED AT THE END OF THIS FORM,
CS-SSO Porm Page 1

JRN-1E-2011 10:54 FROM:BELMONT PUBLIC WORKS 704743335S
TO:7046636040 P.1/4
City of Belmont
140.1. East Catawba Street
Belmont, NC 2801
Phone: [phone] Fax: [phone]
FACSIMILE TRANSMITTAL
To: Lon Snider
Fax #: [phone]
From: Danny Whisnant
Phone #: [phone]
Pages: 4 including cover sheet
Date: 1/18/2011
Re: SSO Report

TAN-18-2011 10:55 FROM:BELMONT PUBLIC WORKS 7047493359 TO:7046636040 P.3/4
Grease (Documentation such as cleaning, inspecticns, enforcement actions, past overflow reports,
educational material and distribution -Tare, etc. s ould be available upon request.)
When was the last time this specific line (or wet well) was cleaned? / 17~a90/f
Do you have an enforceable grease ordinance that requires new or retrofit of grease, traps/interceptors? EYeJ No 0 NA❑ NE
Have there been recent Inspections and/or enforcement actions taRen on nearoy restaurants or other
nonresidential grease contributors?
Explain.
Y
v❑NA❑NE
Have there been other SSQs or blockages in this area that were also caused by grease? U Ye48,No ❑ NAD NE
When? 4-,23-la
'ryes, describe them: Ctvc `+0' f Op+s
Have cleaning and inspections ever been increased at this location? tpl.YeErNo ❑ NA❑ NE
Explain.
�t'ec� i� hec4�t;c tpn a_ weekfti \00-$ s
Have educational materials about grease been distributed in the past? YeLi No0 NA❑ NE
When? Twice c . -)ecx
and to whom? �� Cc � d�r�� � errs,bus, ne,s.$e-s
Explain?
Y.ser4 (41.}0 0,,c3rp is ga7rt door -1-3 &Idt toet41CCCW carat►.
If the SSO occurred at pump station, when was the wet well and pumps last checked for grease
accumulation?
Were the floats clean?
Commonta:
❑ Y0:O Nq ❑ NA❑ NE
CS -$SO Form
Page 4

JAN-18-2011 10:55 FROM:BELMONT PUBLIC WORKS 7347493359 TO:7046636040 P.4/4
System Visitation
QRC
Name:
Cer'tit
Date visited:
Time visited:
©Yee
Sackup Elves
How was the 55O. remediated (i.e. Stopped and cleaned up)?
tYto.Z r', (=.SC`- ) `^as' cL
As a representative for the responsible party, 1 certify that the information contained in this report is true and accurate to
the bolt of my knowledge_
Personsubmitting claim:ny W 10,;��
Signature:
Telephone Number.
7c -gat-oar?
Date: t) ! V ac) /
Title: LAYS 'S0perr'rt4t&Clt
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 uaed).
CS-SSO Form
Page 15

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# QXO((o
Incident Number from BINIS 20c (
Incident Reviewed (Date):
Incident Action Taken: BPJ
,/ NOV-2011-DV Qb41
l o r e ®®e u e m e a n a e 1 e• 3• e e s a e e n ©n a ®n a m a 3 e ®e ®e v o e¢ ®®o ■ e■ ®0 ■■ ®e s' e o e o e a a• e 1 a 11c s
Spill Date 1 11)4 (lt Time (o 3S 0_ / pm
Reported Date 1124(„ Time (S S am/ ID
Reported To SWP Staff or EM Staff L.,o"S
Reported By^'N Ljti Phone
Address of Spill 3s I(NP �(-u"
County
Cause of Spill ( re
Gity
Total Estimated Gallons 07e(
Stream fr;t-3 Fish Kill: Y
Est Gail
Stream >9
Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# (�44
Incident Number from BINIS ZOO OU2S C�
Incident Reviewed (Date):
Incident Action Taken: BPJ
1 ivOV-2011-DV a`-' 2_
l O ®! G! O¢• 0 0 0 9 O O O® 0 m m!\ e i O E i O O o 0 9 o O 16 O 0 o s o o a n© c o m o•® o•• v a m f a M e o c a e® e ®9 O 6
Spill Date i( III Time ('i am/ pdi
Reported Date
'LH "
Time (u 2 (' ram/ pm
Reported To SWP Staff or EM Staff
LS
Reported By cMk L.)
Address of Spill Za c (-e.^-3w � Sd�
Phone
County City
Cause of SpillnoS,
Total Estimated Gallons — Est. Gal to Stream k ? L
Stream Fish Kill: Yes dNo)Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# COO (-(G
Incident Number from BIMS 9kko
Incident Reviewed (Date):
Incident Action Taken: ' PJ
NOV-2011-DV 6 1 (6`a
1 m® 8 E1a 0 9 f© a fl m C® a 6 9 a a O a a a a 6 S C 0 9 a 9 a 0 a 0 m a H a a a O a G m p C a a a a a C a 9 9 a B 9 a 8 M G i C 0 C a a a a E
Spill Date
b r Time am/ rr
I
Reported Date C ?/
Reported To SWP Staff or EM Staff
Time /'Z 0. am/0
1--S
Reported By ``S
Address of Spill +--el
County City 3-elf
Cause of Spill (Yeilik___
Total Estimated Gallons
Stream L)&j Fish Kill: Yes
Phone
Est. Gal to Stream
Number Species
Non Required Information and other comments relating to SSC) incident:
Response time minutes Zone Map Quad

Collection System SSO 24-Hour Notification
Collectio
n System: Number and Name WQCS# (I60
Incident Number from BIMS 20110
Incident Reviewed (Date):
Incident Action Taken:
NOV-2011-DV
DV-2011-
Spill Date
Reported Date
Reported To SWP Staff or EM Staff
l� Phone
Reported By .'.
Address of Spill
Time 0' 35 am/ pm
Time
S
County.
Cause of Spill
Total Estimated Gallons
Stream L&l!
Non Required Information and other comments relating to SSO incident:
Response time minutes
Zone Map Quad
or-A-cr1
Est. Gal to Stream
Fish Kill: Yes N Number Species

Jan 27 10 03:22p
City Of Belmont
7048250514
Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
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 ;QrSca{3,,,Y 6 (WOOS# if active, otherwise use WQCSD#)
Facility: . ecV/C -// , 5 Incident #
• Owner;
City:
Source of SSO (check applicable): rgl Sanitary Sewer ❑
Pump Station /Lift Station
SPECIFIC tocation of the SSO (be consistent in description from past reports or documentation - i.e. Pump Station 6..
Manhole at Westall $ Bragg Street, etc.) ; ,s71{771,'?e' f F 4-, v~,rx >lt71-c-s •t vclY
Manhole#
Latitude (degrees/minute/second);
(mm•dd Incident Started Dt: Ul . 5= 7¢1li Time: a dCnh�.
yyyy) hh;m:rm AM/PM
Estimated volume of the SSO: '? f
gallons
Describe how the volume was determined: .
Weather conditions during SSO event; pn l-_, t45(ef •
Did SSO react, surface waters?
Surfacew ter 9/ j� YgS�RQ© Unknown
a name: /c (rr•cr�
Did the SSO result in a fish kill? a`] Ye, 12 N f^—�
SPECIFICotJ Unknown
❑cau,e(s) of the SSO:
Severe Natural Condition
• 0 Inflow and Infiltration
0 Vandalism
Pipe Failure (Srcak)
Region:
County
Longitude(degrees/minute/second): �'f
incident End Dt:
(mrn.dd-yyyy)
Estimated Duration (Round to nearest hour)' /41
Volume reaching surface waters (gallons); 7I/
1( Yes, what is the estimated number of fig)} kildd?
U Grease
j�"j Pump Station Equipment Failure
0 Debris ;n lino
f -how verbal notification (name of person contacted
�J QWC � [rater
gency Mg t
If an SSO is ongoing, please notify Regional If a S, 7 O the responsible
I issue a press releaewthtn 4&ha disc
the counly`�t�schar our3 of first kno os or
stopped..
shall '^?d9e to
rn.
Date (mm-
• (mrn Time thh:
ot't.fpon
��a daily basis until SSO can bo mm AytIPM).
Refer to the rc ct � � - if 4e published
within/0 ail
cec statute for further detail, / days aria S.S� gallons ub or tion and elgepro •
da
The Director, Division f P3of of publication shalt be
mono r,� ��a , Q Water Quality, may takenf Pro
❑ Root.;
0 Power outage
Other (Please explain in part to
discharge
public notice ge occurr�_ yth more of Untreated
•Per G.S.7q
waters shall
coverage in
Wavers, a p
wastewater Of t
news media o surface
wastewater enter rtling general
i �—��,� Y_ arceittent vided to the Divisionsurface
Y) the discharge °�'rOn fDr within ar o was caused by severe SSQs that 30 days 2) the discharge was exceptional, ¢ ere natural ditipns are roQulr
eo and/or owner. and the unintenti0n2�mPor ark (hare N, to be report.
e discharge could a�` and Bre n clash* Acffo Divisio
nalternatives
unless i
Part 11 must be completed / crated e factor✓ rnativ t
for determinationp eted !o provide a justifi� claim for eft by the exercise of �Sonabe r asod abedischarge; or
�O of a h
any enforcement aerhereforc it is of the a above Situatio a cDntrof trot of the permitleo
WHETHER OR NOT PART II IS important ns• This information
CS-SSO Forrn COMF`D. A S/G1V to be as cOmpret $ o oration will be the b
A7'UR� I$ REQUIRED AT THE END
basis
NO OF r
HIS FORM.
Fo9e

03:22p Cit. Of Belmont
• CATb.—
To: Lonnie Schneier
Fax: 704-663-&46'
Phone:
Re: 5k)---iie—port
Comments:
7048250514
12 Mill Street &Amory, NC 28012 • www.r7ityolbylmouLorrs
Tc/cplionc 704-901,2073 ' Fax 704-82S-0514
Distribution / Collections
FRt;;.76ZE717171/TWZW---
Date: 01/27/10
facsimi
p.1

Jan 27 10 03:22p City 0f Belmont
7048250514 p.4
Pipe Failure (Break)
. Pipe size (inches)
What is the pipe material?
What is tho approximate age of IineJpipe? (years old)
is this a gravity line?
Is this a force Hain lino?
Is the line a "High Priority' line?
Last inspection date and findings
/.2- /. S'- uv9
If a force min then.
Was the break on the force main verified?
Was the break on the force main horizanlal?
Was the leak at the joint duo to gasket failure?
Was the leak at the joint due to split boll?
When was the last inspection or test of tho nearest air -release valve to determine of operable?
When was the last maintenaco of the air release performed?
C /o >,
N/h'
EffYotD No 0 NAO NE
0 Ye4E No NADNE
lEYeDNODNADNE
DYeC NODNADNE
DYecl No0NAO NE
0Ye0 NoDNAL]NE
DYe0 NoCNADNE
If gravity sowor then,
Does the line receive flow from a force main immediately upstream of the failed section of pipe? U Ye4 No 0 NAO NE
If yes, what measures are taken to control the hydrogen sulfide prcduction?
When was the line last inspocled or videeed?
CS-SSO Form Paso y�

Jan 27 10 03:22p City Of Belmont
7048250514 p.3
Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
PART II•
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 l
(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 OF ICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM •
CS-SSOForm
Page 2

Jan 27 10 03:22p City 0f Belmont
7048250514 p.5
If fine collapsed, what is Cho condition of the tine up and down stream of the failure?
f 2 f r.'C' di . % e? r? _
What type of repair was made?
Is the repair iernporary or permanent?
If temporary, when is the permanent repair planned?
Have there been other failures of this lino in the past five years?
If so. then describe
CS-SSO Form
AL' r p •:r':./J rtr�
t_,.J YeaNa 0 NA 0 NE
Page 1,1

Jan 27 10 03:23p City Of Belmont
7048250514 p.6
System Visitation
ORC
Backup
Name:
Certir
Date visited;
Time visited:
How was the SSD remediatcd (Le. Stopped and cleaned up)7
jigYas
0 Yas
-inaZl 4---1 i t174!,/'
a re' c;Yl C C /-{J/ As a representative for the responsible party, l certify that the inform: Lion contained in this report is true and accurate to
t e est o my now e gc,
f ersorl submitting claim_
Signature;
Telephone Number:
70v/. 9,Ol • .2 7
Date: 6/72 7%te4/6"
Title; if fi (6)//rE>l�cxrs�i .ti/f,n C.I—
ct-Gr�
Any additional information desired to be submitted should be sent' the appropriate Qlvision Regional Office within five days of first
icno•vtcdge of the SSO with reference to the incident number (the i cident number is only generated when electronic entry of this
form is completed, if used).
CS-SSO Form
Page 15

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# (l C 006 o
Incident Number from BIMS r .) 1 OCC I
Incident Reviewed (Date):
Incident Action Taken: BPJ
NOV-2009-DV
Spill Date /1 2 S /v Time p2= PU am/
7/()Reported Date /72 Time , r J3 U am/ pm
Reported To SWP Staff or EM Staff6,ti O
Reported By ��tv2cf �iGt,3-ei'k Phone
Address of Spill 6:
County
Cause of Spill
Total Estimated Gallons
Stream L,fr,
City
7 9f 6z6S
Est. Gal to Stream S�
Fish Kill: Yes No Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

Permit #
WQCS00253
WQCS00196
WQCS00233
WQCS00001
WQCS00016
WQCS00046'
WQCS00107
WQCS00089
WQCS00221
WQCS00326
WQCS00088
WQCS00017
WQCS00020
WQCS00327
WQCS00036'
WQCS00040
WQCS00164
WQCS00026
WQCS00059
WQCS00044
WQCS00019
WQCS00037
WQCS00030
WQCS00149
Owner and Facility Name
Bradfield Farms Water Company CS
Carolina Water Service Cabarrus Woods CS
Carolina Water Service Hemby Acres CS
Charlotte -Mecklenburg CS
City of Albemarle CS
City of Belmont CS
City of Bessemer City CS
City of Cherryville CS
City of Claremont CS
City of Concord CS
City of Conover CS
City of Gastonia CS .
City of Hickory CS
City of Kannapolis CS
City of Kings Mountain CS
City of Lincolnton CS
City of Lowell CS
City of Monroe CS
City of Mount Holly CS
City of Newton CS
City of Salisbury CS'
City of Shelby CS
City of Statesville CS
East Lincoln CS
Permit #
WQCS00171
WQCS00322
WQCS00222
WQCS00341
WQCS00231
WQCS00058
WQCS00165
WQCS00342
WQCS00328
WQCS00343
WQCS00310
WQCS00120
WQCS00344
WQCS00043
WQCS00125
WQCS00153
WQCS00190.
Owner and Facility Name
Greater Badin CS
Aqua Country Woods East CS
Town of Boiling Springs CS
Town of China Grove CS
Town of Cleveland CS
Town of Cramerton CS
Town of Dallas CS
Town of E. Spencer CS
Town of Harrisburg CS
Town of Landis CS
Town of Longview CS
Town of Maiden CS
Town of Marshville CS
Town of Mooresville CS
Town of Mt Pleasant CS
Town of Norwood CS
Town of Oakboro CS
WQCS00325 t Town of Stanfield CS
WQCS00180 , Town of Stanley CS
WQCS00135 Town of Taylorsville CS
WQCS00258 Town of Troutman CS
WQCS00345 Town of Wingate CS
WQCS00054 Union County CS
WQCS00009 WSA Cabarrus Co. CS
Deemed Permitted
Permit #
WQCSD0130
WQCSD0114
WQCSD0057
WQCSD0117
WQCS D0257
WQCSD0116
WQCSD0101
WQCSD0095
WQCSD0098
WQCSD0105
WQCSD0107
WQCSD0099
WQCSD0258
WQCSD0112
WQCSD0104
WQCSD0102
Owner and Facility Name
Brooks Food Group -Brooks Food Group
Charlotte Mecklenburg Schools - Misc Laterals
City.of High Shoals CS
Duke Energy Marshall Steam Station
Fallston
Goose Creek Utilities Fairfield Plantation WWTP
Harborside Dev LLC-Midtown T CS
Kennerly Dev. Group LLC-Boardwalk Villas CS
Kennerly Dev. Group LLC-Kings Point CS
Kennerly Dev. Group LLC-Moon Bay Condos CS
Kennerly Dev. Group LLC-Schooner Bay CS
Kennerly Dev. Group LLC-Spinnaker Point CS
Kingstown
Lake Norman -South Point CS
Lake Norman -Villas S Harbour CS
Lake Norman -Vineyard Pt Resort CS
Permit #
WQCSD0064
WQCSD0097
WQCSD0120
WQCSD0019
WQCSD0024
WQCSD0038
WQCSD0002
, WQCSD0049
Owner and Facility Name
Lincoln County CS
Martin Dev Gp-N Point & Portside CS
Martin Marietta Mallard Creek
Town of Richfield CS
Town of Grover CS
Town of McAdenville CS
Town of •Ranlo CS
Town of Spencer Mountain CS
WQCSD0252 All spills which do not have a permit
number assigned

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# ® 0 0 Ci- 6
Incident Number from BIMS 20140 0 6-1 7--
Incident Reviewed (Date): 44751/LC
Incident Action Taken: BPJ
NOV-2014-DV
DV-2014-
Spill Date 3 Time t ' L+5 am pm
Reported Date 3 \ '2-01 4- Time 3. 3 e- am/ prr
Reported To SWP Staff or EM Staff &tiskl
Reported By Dav h Sv\oot -t Phone
Address of Spill toy- g91"' sr
County - G 1:-1/1/4
Cause of Spill Bo kit
City ae-k-not/Ct
4q pw►
Total Estimated Gallons 7 Est. Gal to Stream `ZaD
Stream 1)-o ""c-k , q sc `'v ish Kill: Yes Number Species
Non Required Information and other comments relating to SSO incident: �*-
minutes Zone Map Quad 8 rr 0' ' .
WYNI,Oldi LIS ktiku-UA4(,:k..Q. g() 11):rit4k
PIA- e/' //
to-Nith,L 6qtr) - 9°if
.71
Response time