WQCS00328_Regional Office Historical File Pre 2018

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# (fD
Incident Number from BIMS 20130 it '7/
Incident Reviewed (Date):
Incident Action Taken: a/ BPJ
NOV-2013-DV
DV-2013-
ue�ee��e�e�e a eeseeeee�eee�ee■e�neee�eeeeeo��eee��e��ee�eee■©eeeeeeeeer■
Spill Date
Reported Date
Time 6" - 3 0 am pm
Time `D m' �� wpm
Reported To SWP Staff or EM Staff„
Reported By
Address of Spill !�t
County
Cause of Spill
Phone 6 `1 — / �!'�
0-0 A,/,
City. Y�7,4/t/U 5 G(.A
Total Estimated Gallons A5D Est. Gal to Stream /DSO
Stream Fish Kill: Yes No Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

1
i.�%+��J jti .�.(� � ��-�k�C✓r�) r)���/ ^ CCU ����'!�

a
Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# -3a
Incident Number from BIMS --?O ) �Oc7 j 1q
Incident Reviewed (Date):
Incident Action Taken: ✓ BPJ
NOV-2007-DV
Spill Date a a1 ) �J Time am/ pm
Reported Date e�? i )3 Time O am/ pm
Reported To SWP Staff or EM Staff. �1'Yl V�Cu�
Reported By px,�Phone
Address of Spill P�� /t't. !�'lCt c.e_ 47.
County 064 ba r- r U -S
Cause of Spill
-city -c4lLLC,�t
Total Estimated Gallons 900 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

F
North Carolina Emergency Management - EM43 Reporting
North Carolina Emergency Management - EM43 Reporting
F Print ;Return To List
EM Level:
NCEM Edited:
Include in Report:
4
Yes
Yes
Taken by:
Date/Time Reported:
Date/Time Occurred:
R Dail
02/09/2013 16:58:48
02/09/2013 11:00:48
Reported by:
Agency:
Phone:
Gregory Peifer
Town of Harrisburg
704-239-9762
County:
City:
Area:
Cabarrus
Harrisburg
11
Street Address:
Zip Code:
Outfall off of Penton Place Dr
EVENT TYPE
Type: Wastewater
Animal Disease Event Type: Bomb Threat Event Type:
Complaint Event Type:
Fire Event Type:
FNF Event Type:
FNF Class:
HazMat Event Type:
HazMat Class: HazMat Mode:
Homeland Security Event:
Non-FNF Event: Non-FNF Event Type:
Other Event Type:
SAR Type:
Transportation Event Type: Wastewater Event Type:
Sewage
Weather Event Type: Weather Event Name: WMD Event Type:
State Resource Request
Page 1 of 3
Event Description:
Local utility reported 700 gallons of sewage released from a manhole to the ground and a nearby
pond that overflowed to a creek due to debris. The creek is not a drinking water source, no fish kill
was noted, and cleanup operations were conducted. Ended at 1200.
Filename:
Deaths: Injuries: Evacuation: Radius:
0 0 0 0
Responsible Party: Responsible Party Phone:
Point of Contact: Point of Contact Phone:
Latitude: Longitude:
00.000000-00.000000
RRT Request: RRT Approved: RRT Team RRT Mission
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North Carolina Emergency Management - EM43 Reporting
Page 2 of 3
Number: Number:
https://www.ncsparta.net/eoc7/boards/board.aspx?tableid=275&viewid=1011 &uvid=1.383... 2/11/2013

North Carolina Emergency Management - EM43 Reporting
Page 3 of 3
LEMC:
PD:
CHealth:
PWRK:
AC:
ENV MGMT:
WATER:
CAP:
DOT:
Notes:
Filename:
Filename:
Filename:
Filename:
Filename:
Filename:
Filename:
Filename:
Filename:
NOTIFICATIONS
SO:
LFD:
Sewer:
Other Local Agencies:
SHP/SWP:
DRP:
Other State Agencies:
ATTACHMENTS
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02/,11/201� 13:49 7044554761 TOH PW PAGE 02/05
Farm CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
V 112WO
PART
This fort shall be submitted.to the appropriate DWO Regional Office Within fire days of the first knowledge of
the sanitary sewer overflow (SSO)_
Permit Number : (,�,�d�,<,^FJ (WCjP"CW if active, gtherwise use WQCSD#)
Facility:.� �F Incident #
�-
Owner o rr Region:.C�`!"�,�`
City: f�I County:
Source of SSfl (cheok applicable) : !cr Sanitary -Sewer Pump Station /Lift Station
SPECIFIC location of the SSO (be consistent in d sc iption from .rep its doc man " n -Le. P mp n ,
Manhole at Westalyl�& Brig Street, etc,) : .e29 nd^ /�y 57341
+ 1 I � 6
Manhvle#� Qonn�e tlr7 S �[JI �Af/ s L�l/%�S 6742 5 3 i
.Lptitudo (degtaealminu#eJsecondY n r LOngi#uda4dsgreeslminute/ser�rtd) Q
Incident Started Dt: 0-2 'riM Incident End Dt �Time- t 0
(mm-dd-yyyy) hh:m A M (Mrn-dd-yyyy) hh:mm
Es#imaWdvolurna.oftilt SSOt gallons Estimatad-Durattoa(Round:tone8tlasthour): Z
Describe how the volume was determined: .
Weather conditions during $SO event: —C&IC"---
Did SSO reach surface waters? 14Yes 0`N ❑• Unknown Volume reaching surface waters (gallons):
Surface water name: 4_54A
Did the $SO result in a fish kill? ❑ Yes N Noe Unknown If Yes, what is the eatmated number of fish killed? —
SPECIFIC cause($) Of the SSO:
❑ Severe Natural Condition
❑ Inflow and Infiltration
❑' Vandalism
❑M F'l 12 k
❑ Grease
❑ Pump Station Equipment Failure
N• Debris In line
❑ Roots
❑ Power outage
0Other (please explain'in Part II)
ipe ai ure ( rea ). ,
24-hour verbal notification (name of person contacted)
❑' DWQ R• Emergency Mgmt. Date (mm-od-yyyy);. _OTirne (hh:mm AM M
If an SSO is orrgdng, please notify Regiotal Office on a daily basis tinti'l SSO can be stopped.
Per G.S. 143-21 a,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-WK€ifstiit discharge acourred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a pubtic notice shall be pubi'tshed within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the re rence 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 oemonstratea tnst — - -
1) the discharge was caused by 5ev@re, 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 reawnable-control• of the %rmittee
and/or owner, and the discharge could not have been prevented toy 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 enfvrcenient PctiQ.n. Therefoms; it' is• important to be as complete as possible.
VVH>-THER OR NOT PART It IS COMPLETED, A StGNATLIRE IS REQUIRED AT THE END QF THIS FORM.
CSySSo Form Page 1

02/11/2013 13:49 7044554761 TOH PW PAGE 03/05
Debris in lino (Rocks, sticks, rags and other items not allowed in the colleGtian y) tem, etc,.).
what type of debris has been found in the line?
t
5.
Suspected cause or source of debris.
NO NE
Are manholes in the area seBure and intact?
•Vt•Ihen was the area last checked/leaned?
Czmerw - ire
Have cleaning and Inspoctions ever been increased at this location due to pravious problems with debris? 0 Ye NoJ@NA❑ NE
Explain: `t i 5 G�rr,y, is �d�JyJ�rr�i�a o
Are appropriate eduontiocal materials being eveloped add distributed to prevent fUtjre sll'nllar Ye Np� NA NE
occurrences?
Gommenta;
0
CS-SSO form page 11

02/11/201,3 13:49 7044554761 TOH PW PAGE 04/05
4
Other {pictures and police report, as applicable, must be available upon request,
Describe:
Were adequate equipment and .resources availebte to fix the problem? Ye .Na ld/►tgE
tf Yes, explain: Iq_S t5a04 a.5 ale- 10/%4/..
If the problem could •not•be tnmrnedieteiyrepaired, what act Gm were taken to lessen the impact of the
SSO?
Comments,
CS-SSO Form Page 12

02/11/2013 13:49 7044554761
System Visitation
ORC
Backup
Name:
Cert�
Date visited;
Time visited_
TOH PW
9yes
PAGE 05/05
How wa the SO remelt ted (i.e. Stopped ar�t cleaned up)?
4tc®e4 e //i!, 050,
As a representative for the responsible party, i certify that the information contained in this report is true and accurate to
e . my now e -
Person submitting claim: Date; /!
Signature: �? ,, �i,�� �}'1
Title; L. /" /„- - - - - - i�
!�'
Telephone -Number 7;7e 41 4 7K�
Any additional information desired to be submitted shpuld be sent to the appropriate Division Regional Office within five days of first
knowledge of the SSO vuith reference to the incident number (the incident number is only generated when electronic entry of this
-form is compFeted, [Fused).
CS-SSO Form page 15

02/11/201:3 13:49 7044554761 TOH PW PAGE 01/05
Fax
N I I
I M F - W; Ma r, 010 "'1,
Comments:
Public Wogs Department
P.O. BOX 100
Harrisburg, NC 28075
Fax- [phone]
" W'orking Togotltua' For A Succa ,tiful Futuro�
4100 Main Strett • Suite 101 • P.O. Box 1(9) • Harrisburg. North Carolina 28075 • Telephone [phone] * Fax [phone]

r
Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#
Incident Number from BIMS CAD] 06 YCR3
Incident Reviewed (Date):
Incident Action Taken: _V BPJ
NOV-2008-DV
................................■...........................m.■ 0.00001
Spill Date 311 Time a pm
Reported Date /11-3 Time i %,156 am(pm
Reported To SWP Staff or EM Staff
Reported By
Address of Spill �� � � '� CtGK1
6f-/`a, , A)OVCO
County (V ul`M5 City S &4cl
Cause of Spill — -g GIC�
Total Estimated Gallons � Est. Gal to Stream ��L/
Stream — �� Fish Kill: Yes No Number Species
o�
Non Required Information and other comments relating to SSO incident:
nse time minutes Zone Map Quad
/10
Om 9

03/01/1013 15:54 7044554761 TOH PW PAGE 02/04
V@A'�'yc•� .
Form CS-SSO
Collection System Sanitary Se ter 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 : ('WQCS# if active, otherwise use WQCSQ#).
T '
Facility: Incident #
Owner. Regi
•r
on:
City, County: G2& riJ ._,..
Source of SSO (check applicable) Sanity Se er Q
ry '" Pump Station I Lift Station
SPECIFIC location of the SSO (be consistent in docrjption from p9;t.repos ordocumentatiop -ye. Pump_;xtatijon 8,
Manhole at Wes Ii & Bragg Strgwt, etc.) 2,
Manhole# Q. cn /di/S�yl
- Latitude (dagreew/minute/second): a �f fL7
Incident Started Dt- Time- '
(mm-dd-yyyy) hh: A PM
Estimated volume ofthe SSO: M IA-5� gallons
Describe how the volume was determined:
95 . / - it
Long itude(degreestm inute/second):
Incident End Dt: f Time:
(mm-dd-yyyy) If r(th;mm ��M//
_ estimated Uurption ($.pond to nearest hgur):�_.
Weather conditions during SSO event fG`
1
Did SSO reach surface wate• 7 JN Yes ❑ No❑ Unkn wn Volume reaching sua4Xler e W ters (g ilo ):
Surfacewa#ernam®: iIJE/�� .
�'j R,
Did the SSO result in a fish kill? ❑ Yes NOE] Unknown If 91`es� `what is the �sU—atteanumtSer of fish kilied7
SPECIFIC cause(s) of the SSQ: 14
❑ Severe Natural Condition ❑ Grease ❑ Roots
❑ Inflow and Infiltration ❑ Pump Station Equipment Failure ❑ Power outage
Vandalism tR Debris in line ❑ Other (Please explain in Part 11)
•❑ Pipe Faliure (Break)
f� 24-�hlour verbal notification (name of person contacted) `�` ~
El DWQ ED Emergency Mgmt Date (mm-'dd-yyyy)• AM Time (hh:mm1* JM
ry—
if an SSO is ongoing, please notify Regional office on a daily basis until $SQ can be stopped.
Per G.S. 143-215.1 G(b), the responsible party of a discharge of 1,000 gallon;, or rnore 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 w�F6T IEr-Mscharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shah be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referees statute for further detaii,
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is emons 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 exercise of reasonable control.
Part It must be completed to provide a justification claim for either of the above situations. This information, will be the basis
for the determination of any enforcement action, Therefore, it'is important to be as complete as possible,
WHETHER OR NOT PART it tS COMPLETED A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form Page 1
er, ,

03/01/2013 15:54 7044554761 TOH PW PAGE 01/04
f
Fax
5,
Comments:
O
%V/v
Public Works Department
P.O. Box 100
Harrisburg, WC 20075
Fax. [phone]L
"Worming Togellwr For A Sueuzosfu1 Future
41(X) Main Siroo(* Suite IQ • P.0- Box 1(X) • Harrisburg. North Carolina 2 A)75 •Tetaphot)c [phone] • i=tix(7(ki) 4S5-t206

--103/01/1013 15:54 7044554761 TOH PW PAGE 03/04
i
Debris in line (Racks, sticks, rags and other- items not allowed in the collection system, etc.)
What type of debris has beeeQ found in the line?
17 11/7 E�
� �
S?pe�ted cause or source of debris.. if
w
Are manholes in the area secure and intact? Ye41 No NACD NE
When was the area last Checked/clean ?
Have cleaning and inspections ever been increased at this location due to previous problems with debris? I I Y,0 No ❑ NA❑ NE
Explain: //j!
Are appropriate educational materials being developed and distributed to pfevent future similar Ye No/W N vCJ NE
occurrences?
Comments:/
0
CS-S$C Form Page 11

03/01/2013 15:54 7044554761 TOH PW ; PAGE 04/04:
l., ,
System Visitation
ORC
Backup
Certw
Data visited:
Time visited:
HOW was the S$O rerrme ated (i.eS. opped and cleaned up)?
As a representative for the responsible party, I certify that the information contained in this report is true and accurate to
ffie bez a my now
Person submitting claim:��,�
Signature:
Telephone (dumber.�—
Date, &0 //
C I' I i. /.
J.
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five days of first
knowledge of the SSQ with reference to the incident number (the incident number is only generated when electronic entry of this
form is completed, if used).,
CS-SSd Form Page 15

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# 00 3 .2
Incident Number from BIMS 2013011,51
Incident Reviewed (Date):
Incident Action Taken
M
NOV-20-1-3-DV
DV-2013-
N no A a Y MEXEM E am ONE ME am 0 WE MEN as Munn am am 0*man WHOM a E m s UK ago MUMMM a a Mann on Ono■
Spill Date Zt Q 1 Time 00 am f)
Reported Date ( 4Time � 0 eypm
Reported To SWP Staff or EM Staff G
Reported By6zf P Phone
Address of .Spill 0 t,./e r O c-.I-A
County ,C f City ifc, d✓ r 5 u
Cause of Spill IM 00
w7�/:ffl�
Total Estimated Gallons ()o Est. Gal to Stream 561)C)
Stream of eC� 6'?-e k 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
WQCSD0253 Bradfield Farms Water Company CS
WQCS00196 Carolina Water Service Cabarrus Woods CS
WOCS00233
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
City of Cherryville CS-
WQCS00221
City of Claremont CS
WQCS00326
City of Concord CS
WQCS00088
City of Conover CS
WQCS00017
City of Gastonia CS
WQCSD0020
City of Hickory CS
WQCS00327
City of Kannapolis CS
WQCS00036
City of Kings Mountain CS
WQCS00040
City of Lincolnton CS
WQCS00164
City of Lowell CS
WQCS00026 '
City of Monroe CS
WQCSOD059
City of Mount Holly CS
WOCS00044
City of Newton CS
WQCS00019
City of Salisbury CS
WQCSOOD37
City of Shelby CS
WOCS00030 -
City of Statesville CS
WQCS00149
East Lincoln CS
Deemed Permitted
Permit #
Owner and Facility Name
WQCSD0130
Brooks Food Group -Brooks Food Group
WQCSD0114
Charlotte Mecklenburg'Schools - Misc Laterals
WOCSD0057
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
Kennedy Dev. -Group LLC-Boardwalk Villas CS
WQCSD0098
Kennedy Dev. Group LLC-Kings Point CS
WOCSD0105
Kennedy Dev. Group LLC-INoon Bay Condos CS
WQCSD0107
Kennerly Dev. Group LLC-Schooner Bay CS
WQCSQ0099
Kennedy 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
'WQCS00171
Greater Badin CS
WQCS00322 Aqua Country Woods East CS
WQCS00222
Town of Boiling Springs CS
WQCS00341
Town. of China Grove CS
WQCSD0231
Town.Df Cleveland CS
WQCS00058
Town of Cramedon 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
WOCS00344
Town of Marshville -CS
WOCS00043
Town of Mooresville CS
WQCS00125
Town of Mt Pleasant CS.
WQCS00153
Town of Norwood CS
WQCS00190
Town of Oakboro CS
WOCS00325
Town of Stanfield CS
WQC800180
Town of Stanley CS
WOCS00135
Town of Taylorsville CS
WQCS00258
Town of Troutman CS
WQCS00345
Town of Wingate CS
WQCS00054
Union County CS
WQCS00009
WSA Cabarrus Co. CS
Permit#
Owner and Facility Name
WOCSD0064
Lincoln County CS
WQCSDD097
Martin Dev Gp-N Point & Porlside 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
WOCSD0049
Town of Spencer Mountain CS
WQCSD0252 All spills which do not have a permit
number assigned
r . 2

r 06/11/2013 13:51 7044554761 TOH PW
PAGE 01/04
Fax
Comments:
Fubhc Worms Department
F,Q, Box 100
Harrisburg, NC 28075
Fax: [phone]JL
"gca'kin� Tit,gcihnr Fur A SuccmijfuI Fuiur:"
4100 Maur S(FL-ct 4 Sui(c 1al ► P.U.1B(Ix 100 • ilanisburg. Nlwln Caro] na 28075 + TWephof)c [phone] + Fax (7()4j •155-1 z06

06/11/2013 13:51
7044554761 TOH PW PAGE 02/04
sSo
Collection System Sanitary Sewer 0v�rflow Form Reporting Form
V 1112009
This form shall be s overflow (s the epproprlate DWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSq), _ ,
Permit Number, j,15!!� �0� �,r�
- �'T't (WgQS# if active, otherwise use WQCSD#
Facility; f
Owner.
ti
City; 1
Suurce of SSO (check applicable
) 0 Sanitary Sewer ❑
Incident #
Region:
County;
SPECIFIC location of the SSO (be consWent in a alp ion from ast, Pump Station / Lift Station
Manhole at Westall & Bragg p reports or documantati�
Manhole# d�9 Sheet)
5' D
Latitude (degrees/minute/second): y
Incident Started Dt .>Crh� _ 'Y ime: 6
(mm-dd-yyyy) hh'MM AM"
estimated volume of the SSO; _ gallons
Describe how the volume was determined; i
Weather conditions during SSt7 event �f
Did SSO reach surface waters? Yes ❑ Not_t Unknown
Surface water name; a
Did the SSO result in a fish kill? ❑ Ye Noy Unknown
SPECIFIC oause(s) of the $SO:
❑ Severe Natural Condition
❑ Inflow and Infiltration
❑ Vandalism .
❑ Pipe Failure (great[)
24-hour verbal notification (name of person
ED DWQ ❑ Emergency Mgmt
Station 6,
PART I
L Longitude(degrees!minute/encore):IP
_ 02 122 2 A
Incident End pt; rme.�j
(rr'm c!d YYYY) hh:mm AM/PM
Estimated D r tion Round to 9wrest, r
Volume reaching surface waters (gallons);w
If Yes, what is the estimated nurrlber of fish killed?----_
❑ Grease
❑ Pump Station Equipment Failure
❑ Debris in line
Date
❑ Roo#s
Power outage
❑ Other (Please explain In part 11)
Time
Ifen SSO is ongping, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215. C(b), the nasponsfb o party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 4&hours of first knowledge to all print and electronic news media providing general
Coverage in the countY-W!1;rUTftVscharge occurred When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to th-0-m-IFF-en—ce-a statute for further detail.
The Director, Division of Water Quality, may take enforcement actlor' for SSOs that are required to be reported to Division unless It
rs crone ra a ; _
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unirrtantional, temporary and caused by factors beyond the reasonable control of the Permitted
and/or owner, and the discharge could riot have been prevented by the exercise of reasonable control.
Part It must be completed to provide a justification claim for either of the above situations. This information will be.the basis
for the determination of any enfbmentent action. Therefore. I is Important to be as complete a$ possible.
WHITHER OR NOT FART Il 1S C�MPLI= ISO, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
08-380 Form
Page 1
70 -A;;a0 -l64q
goo- R.h"43--634A

_d'
06/11/2013 13:51 7044554761 TOH PW PAGE 03/04
Power outage (Documentation of testing, records, etc., should be provided of alternative pyye r
upon reques ,
source
What Is your alternate er o pumpin ssi urce?
� ` 1-e'7 *wc/
Did it function prgpe�
Ye Nb [J iVA[J NE
When Was e alternate pow r or pumping Source lest t t nder load?
It caused by a weather event, how much advance warnln id
pre re far the even#? �,d YOU have and what acpons were
• 7v� s Qir sfe9s�`j/�/?rr/ij
otl7a' ,
%k- '0�e '5,
taken to
V
GS-Z tUQ Form
page 9

06/11/2013 13:51 7044554761
Sy -stem visitation
ORC
Backup
Name:
Cart#
Date visited:
Time visited:
How Ms the SSO rem fated i_e. q vaned up)?
TOH PW
h�
PAGE 04/04 i
Y.
As a representative for the responsible party, I certify that the Information contained in this report is true and accurate to
e s o my now a ge.
Person submitting claim:
Signature:
Telephone Number.
Date: 6�1111'
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within live days of first
knowledge of the SSQ vOth reference to the incident number (the incident number is only generated when electronic entry of this
form is completed, if used).
OS-SSO Form
Page 15

Collection System SS® 24-dour Notification
Collection System: Number and Name WQCS#
Incident Number from BIMS
Incident Reviewed (Date):
Incident Action Taken: BPJ
} .f.. v10 f, NOV-2011-DV
DV-2011-
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Spill Date �/,i
Reported Date ') ,;� L S
Time
an, C/PT­)
Time
Reported To SWP Staff or EM Staff
Reported By �, .�^�� �-� Phone
Address of Spill
County —city
'. C�vvu S UWI�
�UtC/�tl`I` S y
Cause of Spill
Total Estimated Gallons —� Est. Gal to Stream
Stream MaAd
�� Fish Kill- Yes No Number Species
Non Required Information and other comments relating to SSO incident'. Q
Map Quad
Response time minutes Zone
& ko