WQCSD0258_Regional Office Historical File Pre 2018

FIL
ROY COOPER
Cover -riot
MICHAEL S. REGAN
Secretary
S. DANIEL SMITH
Director
NORTH CAROLINA
Environmental Quality
CERTIFIED MAIL #: 7018 0360 0002 2099 8184
RETURN RECEIPT REQUESTED
July 21, 2020
Clarissa Jennings -Reid, Mayor
Town of Kingstown
2014 Kingston Rd
Kingstown, NC 28150
SUBJECT: NOTICE OF VIOLATION
Tracking Number: NOV-2020-DV-0254
Sanitary Sewer Overflows - April 2020
Collection System Permit No. WQCSD0258
Kingstown Collection System
Cleveland County
Dear Mrs. Reid:
The self -reported Sanitary Sewer Overflow (SSO) 5-Day Report submitted by Town of Kingstown 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
202001285 4/30/2020
75 1023 West Zion
Church
Road/Kingstown Pump
Station
Inflow and Infiltration
1,125 1,125 Notice of Violation
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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 60
business days following receipt of this violation. Please include any additional documentation about this incident(s)
in the response. The submittal will be considered in determining whether the Division will assess a civil penalty for
the cited violations.
If you have any questions, please do not hesitate to contact Michael Meilinger or me with the Water -Quality Section
-`"" ''" ' "^ --via email at [e-mail] or
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$' Clarissa Jennings -Reid, Mayor
Town of Kingstown
2014 Kindston Rd.
g Kingstown, NC 28105
NOV-2020-DV-0254 WOCSD0250
PS Form 3800, April 2015 PSN 7530-02-000-9047
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'681 AF27425...
Basinger, Regional Supervisor
ality Regional Operations Section
le Regional Office
f Water Resources, NCDEQ
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FILE
ROY COOPER
Governor
MICHAEL S. REGAN
Secretor
S. DANIEL SMITH NORTH CAROLINA
Director Environmental Quality
CERTIFIED MAIL #: 7016 1370 0000 2592 0577
RETURN RECEIPT REQUESTED
May 21, 2020
Clarence Withrow, Mayor
Town of Kingstown
2014 Kingston Rd
Kingstown, NC 28150
SUBJECT: NOTICE OF VIOLATION
Tracking Number: NOV-2020-DV-0254
Sanitary Sewer Overflows - April 2020
Collection System Permit No. WQCSD0258
Kingstown Collection System
Cleveland County
Dear Mr. Withrow:
The self -reported Sanitary Sewer Overflow (SSO) 5-Day Report submitted by Town of Kingstown 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
202001285 4/30/2020 75 1023 West Zion , Inflow and Infiltration 1,125 1,125 Notice of Violation
Church
Road/Kingstown Pump
Station
Nert Cn o' 3 Department pfEnvronrneht C,? ha?rLy I D- on of Water Rey Ur..- -
I•°var__r ._ R'- -'e Dfc- I c10 Ear tenter Avenu_.5o,t_ 301 I Moo :a.r:,_, rth zro'inz 22;115

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 60
business days following receipt of this violation. Please include any additional documentation about this incident(s)
in the response. The submittal will be considered in determining whether the Division will assess a civil penalty for
the cited violations.
If you have any questions, please do not hesitate to contact Michael Meilinger or me with the Water Quality Section
in the Mooresville Regional Office at 704-663-1699 or via email at michael.meilinger©ncdenr.gov or
[e-mail].
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CERTIFIED MAIL° RECEIPT
Domestic Mall Only
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F ] C A L USE
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Adult Signature Restricted Delivery $
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2014 KINGSTON ROAD
KINGSTOWN NC 28150
ATTN: CLARENCE WITHROW, MAYOR
Dwr/mm 5/21/2020
PS Form 3800, April 2015 PSN7530-02-000-9047
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See Reverse for Instructions
WQROS OFFICE
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isinger, Regional Supervisor
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Regional Office
Vater Resources, NCDEQ
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704-SC3-169 9

ROY COOPER
Governor
MICHAEL S. REGAN
Secretnry
S. DANIEL SMITH
Director
srArE •
NORTH CAROLINA
Environmental Qualify
CERTIFIED MAIL #: 7018 0360 0002 2099 7965
RETURN RECEIPT REQUESTED
April 22, 2020
Clarence Withrow, Mayor
Town of Kingstown
2014 Kingston Rd
Kingstown, NC 28150
SUBJECT: NOTICE OF VIOLATION
Tracking Number: NOV-2020-DV-0152
Sanitary Sewer Overflows - February 2020
Collection System Permit No. WQCSD0258
Kingstown Collection System
Cleveland County
Dear Mr. Withrow:
FILE
The self -reported Sanitary Sewer Overflow (SSO) 5-Day Report submitted by Town of Kingstown 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
202000458 2/6/2020 290 1623 W Zion Church Severe Natural 12,700 12,700 Notice of Violation
Rd (Kingstown LS) Condition Severe Natural Condition
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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 60
business days following receipt of this violation. Please include any additional documentation about this incident(s)
in the response. The submittal will be considered in determining whether the Division will assess a civil penalty for
the cited violations.
If you have any questions, please do not hesitate to contact Michael Meilinger or me with the Water Quality Section
in the Mooresville Regional Office at 704-663-1699 or via email at michael.rneilinger©ncdenr.gov or
corey.basinger@a ncdenr.gov.
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FIIIA L U S E
Extra Services & Fees (check box, add fee as appropriate)
❑ Retum Receipt (hardcopy) $
['Return Receipt (electronic) $
❑ Certified Mall Restricted Delivery $
❑ Adult Signature Required $
❑ Adult Signature Restricted Delivery $
Postage
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City
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TOWN OF KINGSTOWN
2014 KINGSTON ROAD
KINGSTOWN NC 28150
ATTN: CLARENCE WITHROW, MAYOR
Dwr/mm 4/22/2020
CC681 AF27425...
!y Basinger, Regional Supervisor
)uality Regional Operations Section
fille Regional Office
of Water. Resources, NCDEQ
PS Form 3800, April.2015. PSN 7530-02-000-9047 See Reverse for Instructions
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- ------1M-MCAC-O2T-:0403 - PERMITTING BY REGULATION
Permittee: Awl.
Trac!ding #: WQCSDO'7 g'
Date:
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•POC Phone:
POC: -
(a) Collection systems having an actual, permitted or
Division approved average daily flow less than 200,000
gallons per day are deemed permitted pursuant to Rule .0113
of this Subchapter provided the system meets the criteria in
Rule .0113 of this Subchapter and all specific criteria
required in this Rule:
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REMARKS'
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(1) The sewer system is effectively maintained and operated
at all times to prevent discharge to land or surface waters,
and to prevent any contravention of groundwater standards
or surface water standards.
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(2) A map of the sewer system has been developed and is
actively maintained .
.
(3) An operation and maintenance plan including. pump
station inspection frequency., preventative maintenance •
schedule, spare parts inventory and overflow response has
been developed and implemented. -
(4) Pump stations that are not connected to a telen etry
system (Le., remote alarm system) are inspected by the
permittee or its representative every day (i.e., 365 days per •
year). Pump stations that are connected too telemetry
system are inspected at least once per week.-
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(5) High -priority sewers are inspected by the permittee or its
representative at least once every six-months.and
inspections are documented.
. . .
.
(6) A general observation by the permittee or its
representative of the entire sewer system is conducted at
least once per year.
✓•
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Overflows and bypasses are reported to -the appropriate
Ct) yp P
Division regional' office in accordance -with 15A NCAC 02B
.0506(a), and public notice is provided as required by G_S.
143-215,1 C. .
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A Grease Control Program is in place as follows`
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(A) For publicly owned collection systems, ttie Grease
Control Program shall include at least bi-annual distribution of
educational materials for both commercial and residential
and .the legal means to require grease interceptors fore
new construction and retrofit if necessary, of grease
at existing establishments. The plan shall also
include legal means for inspections of the grease _
interceptors; enforcement for violators and the legal means to
control grease entering the system from other public and
private satellite sewer systems. .
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(B) For privately owned collection systems, the Grease
include least bi-annual distribufier
• .•
Control Program shall at
grease education materials to users of the collection system
by the or its representative.
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.
permittee
(C) Grease education materials shall be.distributed more
• often than required in Parts (A) and (B) of this Subparagraph
if necessary to prevent grease -related sanitary sewer
overflows.
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(9) Right-of-ways and easements are maintained in the full
easement width for personnel and equipment accessibility.
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(10) Documentation shall be kept for Subparagraphs (a)(1)
—__....i, I..vM nf+hie Pula fry a minimum of three years with
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Pump Station Inspection Checklist
Name:
• ii2,C
Address:
2.ois Rai
# Pumps -
•
Working
Run Time -
W.eather: .
Signage:
•
YES
NO
Housekeeping:
l.Secure: •
Wet Well Floats:
Debris:.
Working High Water Float
Telemetry: •
SCADA:
AudioNisual:
Is alarm systeM tested, How often:
•
I.nspection Logs:
Emergency Power
Type: Portable
•
Juick Connect.
nsite Fuel - G ScheduleNender -
resting Schedule:
3ackflow:
Nei -flow Piping:
3ypass Pumping:
•
nspection Schedule:
omments/ ObserVations:
dtvq/10-
co)-(01/1

Pump Station InspeCtion Checklist
Name:
Kiv135,171wV\
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Address:
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#Punlps -
Working
1
2
2
Run rune -
Weather:
Signage:
'Housekeeping:
! .Secure:
Wet Well Floats:
Debris: .
Working High Water Float
telemetry:_.
SCADA. •
YES
z
NO
AudioNisuat
Is alarm system tested, How often:
Inspection Logs:
Emergency Power.
Type: Portable
•
Duick Connect: .-
resting Schedule:
3ackflow:
t.
Fuel -9'e,S4 Schedule/Vender -
tiretk-1
)verflow Piping:
3ypass Pumping:
nspection Schedule:
;omments/ Observations:
(

2018 Kingstown Sewer Records Report
Sewer Line Maintenance & Repair- 0 in 2018
Preventative Maintenance- 1.7 miles in 2018 (18.4 % of Kingstown System)
ROW Maintenance- 5.3 miles in 2018
Sewer Camera- 0 miles in 2018
Acoustic Testing- 0 miles in 2018
Manhole Inspections- 67 in 2018
Manhole Maintenance & Repair- 0 in 2018

2019 Kingstown Sewer Records Report
(8.28.2019)
Sewer Line Maintenance & Repair- 0 in 2019
Preventative Maintenance- 0.7 miles in 2019 (7.6 % of Kingstown System)
ROW Maintenance- 5.1 miles in 2019
Sewer Camera- 0.2 miles in 2019
Acoustic Testing- 0 miles in 2019
Manhole Inspections- 140 in 2019
Manhole Maintenance & Repair- 0 in 2019

Water Resources
Environmental Quality
May 4, 2017
Mr. David Hux, Assistant Utilities Director
City of Shelby
Post Office Box 207
Shelby, North Carolina 28151-0207
Subject: Compliance Evaluation Inspection
Permittee: Kingstown Collection System
Permit No. WQCSD0258
Cleveland County
Dear Mr. Hux:
1
., ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
S. JAY ZIMMERMAN
Director
'1. Mr. Barry Love of the Mooresville Regional Office of the NC Division of Water Resources
(DWR or the Division) conducted a compliance evaluation inspection (CEI) of the
Kingstown wastewater collection system (WWCS) on April 24, 2017. The assistance of all
those present during the inspection was greatly appreciated. A copy of the inspection report
is attached for your records and inspection findings are summarized below.
Site/System Review
2. The following system components were inspected:
a. Two pump stations were inspected with no problems being found.
b. Four manholes were inspected with no problems being found.
c. Two sections of right-of-way were inspected with no problems being found.
3. As you are aware, owners of deemed permitted collection systems must comply with all
rules listed under NC Administrative Code 15A NCAC 02T .0400, et seq. Kingstown's
compliance status with each of these rules is summarized below:
a. 15A NCAC 02T .0403(a)(1): Requires that the system be effectively maintained
and operated at all times to prevent discharge to land or surface waters and any
contravention of ground or surface water standards.
Observations: There have been no overflows in this system in the past several
years. The last occurred on 07/1/2011 due to grease. This system appears to be
well maintained and operated.
Compliance Status: Compliant
-=�Nothing Compares:=-.._r
State of North Carolina i Environmental Quality I Water Resources I Water Quality Regional Operations
Mooresville Regional Office 1610 East Center Avenue, Suite 301 i Mooresville, North Carolina 28115
704-663-1699

b. 15A NCAC 02T .0403(a)(2): Requires that a map of the wastewater collection
system be developed and actively maintained.
Observations: A copy of the map was available at the time of inspection.
Compliance Status: Compliant
c. 15A NCAC 02T .0403(a)(3): Requires that an operation and maintenance (O&M)
plan be developed and implemented, which includes pump station inspection
frequency, preventative maintenance schedule, spare parts inventory and overflow
response.
Observations: The system appeared to be well maintained with protocol set up to
address any needs.
Compliance Status: Compliant
d. 15A NCAC 02T .0403(a)(4): Requires that the permittee or its representative
inspect pump stations that are not connected to a telemetry system (i.e., remote
alarm system) every day (i.e., 365 days per year) and pump stations that are
connected to a telemetry system at least once per week.
Observations: Records showed that both pump stations are inspected on a weekly
basis and are well maintained.
Compliance Status: Compliant
e. 15A NCAC 02T .0403(a)(5): Requires that the permittee or its representative
inspect high -priority sewers (HPS - as defined in 15A NCAC 02T .0402(2)) at least
once every six months and document the inspections.
Observations: There are no high -priority lines on this system.
Compliance Status: NA
f. 15A NCAC 02T .0403(a)(6): Requires that the permittee or its representative
conduct a general observation of the entire wastewater collection system at least
once per year.
Observations: Annual observations of the entire system should be conducted and
documented. This appears to be met through right-of-way maintenance, line
cleaning and other maintenance checks.
Compliance Status: Compliant.

g.
15A NCAC 02T .0403(a)(7): Requires .that overflows and bypasses from the
system be reported to the Division's Mooresville Regional Office in accordance
with 15A NCAC 02B .0506(a), and that public notice must be provided as required
by G.S. 143-215.1C.
Observations: This system had a SSO on 07/01/11. This SSO was reported but
didn't require public notice since 318 gallons reached the stream. The NC
regulations and statutes, which cover the reporting requirements for SSOs, are
found in NC Administrative Code 15A NCAC 02B .0506(a) and NC General
Statute 143-215.1 C, respectively. You may access the NC regulations online at the
NC Office of Administrative Hearings (OAH) website at:
http://www.oah.state.nc.us/rules/ and the NC General Statutes online at the NC
General Assembly's website at:
http://www.ncga.state.nc.us/gascripts/Statutes/StatutesTOC.p1. You may wish to
review them to ensure you are fully familiar with all requirements.
When reporting SSOs to DWQ, you must call the Mooresville Regional Office
(MRO) at 704-663-1699 during normal business hours. If outside normal business
hours, you must report the spill to the NC Division of Emergency Management at
1-800-858-0368. Please note that all reportable SSOs must be reported within 24
hours of the occurrence, or first knowledge, of the SSO. Please also note that voice
mail or faxed messages are not considered as the initial verbal report. You must
talk to and report the spill to a live person.
Compliance Status: Compliant
h. 15A NCAC 02T .0403(a)(8): Requires that a grease control program be developed
and implemented as follows:
1. For privately owned collection systems, the Grease Control Program shall
include at least bi-annual distribution of grease education materials to users
of the collection system by the permittee or its representative.
2. Grease education materials shall be distributed more often than required
above if necessary to prevent grease -related sanitary sewer overflows.
Observations: Shelby provides bill stuffers to the Town of Kingstown to send out.
Shelby also provides grease education materials at local festivals which cover the
Kingstown area. Kingstown is required to adopt Shelby's grease rules.
Compliance Status: Compliant.
i. 15A NCAC 02T .0403(a)(9): Requires that right-of-ways (ROW) and easements
be maintained in the full easement width for personnel and equipment accessibility.

r
Observations: The right-of-ways inspected were found to be well maintained.
Compliance Status: Compliant.
j. 15A NCAC 02T .0403(a)(10): Requires that documentation be kept for all
activities you undertake to comply with the requirements of 15A NCAC 02T .0403,
subparagraphs .(a)(1) through (a)(9), for a minimum of three years, with the
exception of the map, which shall be maintained for the life of the system.
Observations: Required records are kept.
Compliance Status: Compliant
Please take special note of the comments in each section of the inspection report for areas which
may need to be improved upon or addressed. If you have any questions regarding this letter please
give me or Barry Love a call at 704-663-1699.
Sincerely,
�-Ja W. Corey Basinger, Regional Supervisor
Mooresville Regional Office
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ
Attachments:
1. BIMS Inspection Report
CC: 1 IR@;
Central Files
PERCS Unit
Town of Kingstown

w
Compliance Inspection Report
Permit: WQCSD0258 Effective: 07/06/07 Expiration: Owner : Town of Kingstown
SOC: Effective: Expiration: Facility: Kingstown Collection System
County: Cleveland
Region: Mooresville
Contact Person: Clarence Withrow
Directions to Facility:
Title: Mayor Phone: [phone]
System Classifications:
Primary.ORC: Certification: Phone:
Secondary ORC(s):
On -Site Representative(s):
Related Permits:
NC0024538 City of Shelby - First Broad River WWTP
Inspection Date: 04/24/2017
Entry Time 10:OOAM Exit Time: 02:30PM
Primary Inspector: Barry F Love Phone: [phone] Ext.263
Secondary Inspector(s):
Reason for Inspection: Routine Inspection Type: Collection System Inspect Non Sampling
Permit Inspection Type: Deemed permitted collection system management and operation
Facility Status: II Compliant ❑ Not Compliant
Question Areas:
• Miscellaneous Questions
▪ Records
• Pump Station
(See attachment summary)
▪ Performance Standards
▪ Monitoring & Rpting Reqmts
▪ Manhole
• Operation & Maint Reqmts
• Inspections
II Lines
Page: 1

Permit: WQCSD0258 Owner - Facility:Town of Kingstown
Inspection Date: 04/24/2017
Inspection Type : Collection System Inspect Non Sampling Reason for Visit: Routine
Inspection Summary:
Page: 2

Permit: WQCSD0258 Owner - Facility: Town of Kingstown
Inspection Date: 04/24/2017
Inspection Type : Collection System Inspect Non Sampling Reason for Visit: Routine
Inspections
Are maintenance records for sewer lines available?
Are records available that document pump station inspections?
Are SCADA or telemetry equipped pump stations inspected at least once a week?
Are non-SCADA/telemetry equipped pump stations inspected every day?
Are records available that document citizen complaints?
# Do you have a system to conduct an annual observation of entire system?
# Has there been an observation of remote areas in the last year?
Are records available that document inspections of high -priority lines?
Has there been visual inspections of high -priority lines in last six months?
Comment: System contains two pump stations which are inspected weekly.
Monitoring and Reporting Requirements
Are copies of required press releases and distribution lists available?
Are public notices and proof of publication available?
# Is an annual report being prepared in accordance with G.S. 143-215.1C?
# Is permittee compliant with all compliance schedules in the permits?
If no, which one(s)?
Comment:
Operation & Maintenance Requirements
Are all log books available?
Does supervisor review all log books on a regular basis?
Does the supervisorhave plans to address documented short-term problem areas?
What is the schedule for reviewing inspection, maintenance, & operations logs and problem areas?
Are maintenance records for equipment available?
Is a schedule maintained for testing emergency/standby equipment?
What is the schedule for testing emergency/standby equipment?
Do pump station logs include:
Inside and outside cleaning and debris removal?
Inspecting and exercising all valves?
Inspecting and lubricating pumps and other equipment?
Inspecting alarms, telemetry and auxiliary equipment?
Is there at least one spare pump for each pump station w/o pump reliability?
Yes No NA NE
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1000
❑ ❑ 11 ❑
Page: 3

Permit: WQCSD0258 Owner - Facility: Town of Kingstown
Inspection Date: 04/24/2017
Inspection Type : Collection System Inspect Non Sampling Reason for Visit: Routine
Operation & Maintenance Requirements
Are maintenance records for right-of-ways available?
Are right-of-ways currently accessible in the event of an emergency?
Are system cleaning records available?
Has at least 10% of system been cleaned annually?
What areas are scheduled for cleaning in the next 12 months?
Is a Spill Response Action Plan available?
Does the plan include:
24-hour contact numbers
Response time
Equipment list and spare parts inventory
Access to cleaning equipment
Access to construction crews, contractors, and/or engineers
Source of emergency funds
Site sanitation and cleanup materials
Post-overflow/spill assessment
Is a Spill Response Action Plan available for all personnel?
Is the spare parts inventory adequate?
Yes No NA NE
• ❑ ❑ ❑
• ❑ ❑ ❑
• ❑ ❑ ❑
U ❑ ❑ ❑
MI ❑ ❑ ❑
• ❑ ❑ ❑
■ ❑❑❑
▪ ❑ ❑ ❑
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❑ ❑ ❑IN
❑ ❑ ❑ ❑
® ❑ ❑ ❑
❑❑❑■
▪ ❑ ❑ ❑
Comment: Pump stations are well maintained with thorouqh records to document this. 1.03 miles (11%) of
line was cleaned this past year. Generators are tested on a weekly basis.
Performance Standards
Is Public Education Program for grease established and documented?
What educational tools are used?
Shelby operates system and provides flyers to Kingstown to mail out. Shelby also does education at local
festivals which cover the Kingstown area.
Is Sewer Use Ordinance/Legal Authority available?
Does it appear that the Sewer Use Ordinance is enforced?
Is Grease Trap Ordinance available?
Is Septic Tank Ordinance available (as applicable, i.e. annexation)
List enforcement actions by permittee, if any, in the last 12 months
Has an acceptable Capital Improvement Plan (CIP) been implemented?
Does CIP address short term needs and long term Vmaster plan\" concepts?
Does CIP cover three to five year period?
Does CIP include Goal Statement?
Does CIP include description of project area?
Yes No NA NE
■ ❑❑❑
❑ ❑ ❑
1:11110111
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Page: 4

Permit: WQCSD0258 Owner - Facility:Town of Kingstown
Inspection Date: 04/24/2017
Inspection Type : Collection System Inspect Non Sampling Reason for Visit:. Routine
Performance Standards Yes No NA NE
Does CIP include description of existing facilities'? 0 0 NI 0
Does CIP include known deficiencies? 0 ❑ • 0
Does CIP include forecasted future needs? 0 ❑ 11 ❑
Is CIP designated only for wastewater collection and treatment? 0 0 • 0
Approximate capital improvement budget for collection system?
Total annual revenue for wastewater collection and treatment?
CIP Comments
Is system free of known points of bypass? • 0 0 0
If no, describe type of bypass and location
Is a 24-hour notification sign posted at ALL pump stations? • ❑ ❑ 0
# Does the sign include:
Instructions for notification? • ❑ ❑ 0
Pump station identifier? • ❑ ❑ 0
24-hour contact numbers • 0 0 ❑
If no, list deficient pump stations
# Do ALL pump stations have an "auto polling" feature/SCADA? 00010
Number of pump stations 2
Number of pump stations that have SCADA 0
Number of pump stations that have simple telemetry 2
Number of pump stations that have only audible and visual alarms 0
Number of pump stations that do not meet permit requirements 0
# Does the permittee have a root control program? ❑ 0 ® 0
# If yes, date implemented?
Describe:
Comment: Shelby operates/maintains the system for Kingstown and requires local government to adopt
their rules for grease.
Records
Are adequate records of all SSOs, spills and complaints available?
Are records of SSOs that are under the reportable threshold available?
Do spill records indicate repeated overflows (2 or more in 12 months) at same location?
If yes, is there a corrective action plan?
Is a map of the system available?
Does the map include:
Yes No NA NE
• ❑ ❑ ❑
❑ ❑ • ❑
❑ ❑ II ❑
❑ ❑ • ❑
• ❑ ❑ ❑
Page: 5

Permit: WQCSD0258 Owner - Facility:Town of Kingstown
Inspection Date: 04/24/2017
Inspection Type : Collection System Inspect Non Sampling Reason for Visit: Routine
Records Yes No NA NE
Pipe sizes 11 ❑ ❑ ❑
Pipe materials •❑ ❑ ❑
Pipe location 11000
Flow direction 11000
Approximate pipe age 00011
Number of service taps •❑ ❑ ❑
Pump stations and capacity 11000
If no, what percent is complete?
List any modifications and extensions that need to be added to the map
# Does the permittee have a copy of their permit? ❑ ❑ 1 ❑
Comment:
ABOVE PETTY RD PS -
Lines/Rig ht-of-Ways/Aeriel Lines
Is right-of-way accessible for emergency?
Is right-of-way free of sinkholes or depressions?
Is line/right-of-way free of evidence of leakage?
# Are there areas of exposed line?
# Is any exposed line constructed of ductile iron or other approved material?
Are water crossing and supports in good condition?
# Is right-of-way free of non -utility motorized traffic?
Is line free of visible damage?
# Are there siphons in this system?
If yes, are they maintained and documented?
Comment: Right-of-way appeared to be well maintained.
AT KINGSTOWN PS -
Lines/Right-of-Ways/Aerie) Lines
Is right-of-way accessible for emergency?
Is right-of-way free of sinkholes or depressions?
Is line/right-of-way free of evidence of leakage?
# Are there areas of exposed line?
# Is any exposed line constructed of ductile iron or other approved material?
Are water crossing and supports in good condition?
# Is right-of-way free of non -utility motorized traffic?
Yes No NA NE
® ❑ ❑ ❑
11000
■❑❑❑
O 0110
O 0110
❑ ❑ l ❑
111000
• ❑ ❑ ❑
O 0011
Yes No NA NE
• ❑ ❑ ❑
• ❑ ❑ ❑
11000
❑ ❑ 1 ❑
O 0110
❑ ❑■❑
1000
Page: 6

Permit: WQCSD0258 Owner - Facility: Town of Kingstown
Inspection Date: 04/24/2017
Inspection Type : Collection System Inspect Non Sampling Reason for Visit: Routine
AT KINGSTOWN PS -
Lines/Right-of-Ways/Aeriel Lines
Is line free of visible damage?
# Are there siphons in this system?
If yes, are they maintained and documented?
Comment: Right-of-way appeared to be well maintained.
KINGSTOWN -
Pump Station
Pump station type
Are pump station logs available?
Is it accessible in all weather conditions?
# Is general housekeeping acceptable?
Are all pumps present?
Are all pumps operable?
Are wet wells free of excessive debris?
Are upstream manholes free of excessive debris/signs of overflow?
Are floats/controls for pumps/alarms operable?
Is "auto polling" feature/SCADA present?
Is "auto polling" feature/SCADA operational?
Is simple telemetry present?
Is simple telemetry operational?
Are audio and visual alarms present?
Are audio and visual alarms operable?
Is the Pump station inspected as required?
Are backflow devices in place?
Are backflow devices operable?
Are air relief valves in place?
Are air relief valves operable?
# Is an emergency generator available?
Can the emergency generator run the pumps?
Is the pump station equipped for quick hook-up?
Is the generator operable?
# Is fuel in tank and sufficient?
Is the generator inspected according to their schedule?
Is a 24-hour notification sign posted?
Does it include:
Yes No NA NE
• ❑ ❑ ❑
❑ ❑ ❑ •
Yes No NA NE
Duplex
• ❑ ❑ ❑
■ ❑❑❑
▪ ❑ ❑ ❑
• ❑ ❑ ❑
• ❑ ❑ ❑
El ❑ ❑ ❑
• ❑ ❑ ❑
• ❑ ❑ ❑
❑ ❑ I ❑
❑ ❑ 1N ❑
• ❑ ❑ ❑
• ❑ ❑ ❑
• ❑ ❑ ❑
▪ ❑ ❑ ❑
• ❑ ❑ ❑
❑ ❑ ❑
❑ ❑ ❑ IN
❑ ❑ ❑ IN
❑ ❑ ❑ II
II ❑ ❑ ❑
• ❑ ❑ ❑
❑ ❑ III ❑
• ❑ ❑ ❑
• ❑ ❑ ❑
II ❑ ❑ ❑
• ❑ ❑ ❑
Page: 7

Permit: WQCSD0258 Owner - Facility: Town of Kingstown
Inspection Date: 04/24/2017
Inspection Type : Collection System Inspect Non Sampling Reason for Visit: Routine
KINGSTOWN -
Pump Station
Instructions for notification?
Pump station identifier?
Emergency phone number
Is public access limited?
Is pump station free of overflow piping?
Is the pump station free of signs of overflow?
Are run times comparable for multiple pumps?
Comment: Pump station appeared to be well maintained with no problems noted.
KINGSTOWN - upstream of PS
Manhole
Is manhole accessible?
# Is manhole cover/vent above grade?
Is the manhole free of visible signs of overflow?
Is the manhole free of sinkholes and depressions?
Is manhole cover present?
# Is manhole properly seated?
# Is manhole in good condition?
# Is invert in good condition?
Is line free -flowing and unrestricted in manhole?
Is manhole free of excessive amounts of grease?
Is manhole free of excessive roots?
Is manhole free of excessive sand?
Is manhole's extended vent screened?
Are vents free of submergence?
Are manholes free of bypass structures or pipes?
Comment: Checked first and third manholes
PETTY ROAD -
Manhole
Is manhole accessible?
# Is manhole cover/vent above grade?
Is the manhole free of visible signs of overflow?
Is the manhole free of sinkholes and depressions?
Is manhole cover present?
Yes No NA NE
• ❑ ❑ ❑
• ❑ ❑ ❑
• ❑ ❑ ❑
• ❑ ❑ ❑
■ ❑❑❑
■ ❑❑❑
Yes No NA NE
RI ❑ ❑ ❑
e❑❑❑
■ ❑❑❑
• ❑ ❑ ❑
R ❑ ❑ ❑
• ❑ ❑ ❑
• ❑ ❑ ❑
© ❑❑❑
▪ ❑ ❑ ❑
111000
■ ❑❑❑
• ❑ ❑ ❑
1110111111
❑ ❑ ® ❑
▪ ❑ ❑ ❑
upstream of the pump station. No problems were observed.
Yes No NA NE
▪ ❑ ❑ ❑
11000
11000
11000
11000
Page: 8

Permit: WQCSD0258 Owner - Facility: Town of Kingstown
Inspection Date: 04/24/2017
Inspection Type : Collection System Inspect Non Sampling Reason for Visit: Routine
PETTY ROAD -
Manhole Yes No NA NE .
# Is manhole properly seated? • ❑ 0 0
# Is manhole in good condition? MOOD
# Is invert in good condition? • 0 ❑ ❑
Is line free -flowing and unrestricted in manhole? • ❑ ❑ ❑
Is manhole free of excessive amounts. of grease? • ❑ 0 0
Is manhole free of excessive roots? IN 0 ❑ ❑
Is manhole free of excessive sand? • 0 ❑ ❑
Is manhole's extended vent screened? ❑ ❑ • 0
Are vents free of submergence? ❑ 0 1 ❑
Are manholes free of bypass structures or pipes? • 0 ❑ ❑
Comment: Checked first and second manholes upstream of pump station. No problems were observed.
PETTY ROAD PS -
Pump Station
Pump station type
Are pump station logs available?
Is it accessible in all weather conditions?
# Is general housekeeping acceptable?
Are all pumps present?
Are all pumps operable?
Are wet wells free of excessive debris?
Are upstream manholes free of excessive debris/signs of overflow'?
Are floats/controls for pumps/alarms operable?
Is "auto polling" feature/SCADA present?
Is "auto polling" feature/SCADA operational?
Is simple telemetry present?
Is simple telemetry operational?
Are audio and visual alarms present?
Are audio and visual alarms operable?
Is the Pump station inspected as required?
Are backflow devices in place?
Are backflow devices operable?
Are air relief valves in place?
Are air relief valves operable?
# Is an emergency generator available?
Yes No NA NE
Duplex
• ❑ ❑ ❑
• ❑ ❑ ❑
II ❑ ❑
II ❑ ❑ ❑
• ❑ ❑ ❑
1 ❑ ❑ ❑
II ❑ ❑ ❑
II ❑ ❑ ❑
❑ ❑ II ❑
❑ ❑ •❑
• ❑ ❑ ❑
• ❑ ❑ ❑
▪ ❑ ❑ ❑
▪ ❑ ❑ ❑
■ ❑❑❑
❑ ❑ ❑ •
❑ ❑ ❑ •
❑ ❑ ❑ •
❑ ❑ ❑ •
• ❑ ❑ ❑
Page: 9

Permit: WQCSD0258 Owner - Facility:Town of Kingstown
Inspection Date: 04/24/2017
Inspection Type : Collection System Inspect Non Sampling Reason for Visit: Routine
PETTY ROAD PS -
Pump Station Yes No NA NE
Can the emergency generator run the pumps? IN ❑ ❑ ❑
Is the pump station equipped for quick hook-up? ❑ ❑ ❑
Is the generator operable? • ❑ ❑ ❑
# Is fuel in tank and sufficient? •❑ ❑ ❑
Is the generator inspected according to their schedule? 110111 ❑
Is a 24-hour notification sign posted? ®❑ ❑ ❑
Does it include:
Instructions for notification? • ❑ ❑ ❑
Pump station identifier? • ❑ ❑ ❑
Emergency phone number M ❑ ❑ ❑
Is public access limited'? • ❑ ❑ ❑
Is pump station free of overflow piping? • ❑ ❑ ❑
Is the pump station free of signs of overflow? • ❑ ❑ ❑
Are run times comparable for multiple pumps?
Comment: Pump station appeared to be well maintained.
Page: 10

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1. Number of Pump stations 5
2. SCADA. system PS 2.
3. •TeleUl:etry PS
4. Audible and visual only
5. Generators Permanent
a. Frequency tested 1 /w k
3
Generators Portable
A. Quick -connect p1ugin PS
. Frequency tested
Pump stations served by same generator.
6.
RC .1 )D 1i ; b ®
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Sewer Use Ordinance
c $i1-1Ly
P O go,,e 7
51, L NG zS7I31-© -02
spection Check .gt
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n �L .'r'a Irb,.VG t r ✓ry11
]Ennforce, eats Last Year• ; 044:4. ,l�w?P• • =�n
FOG Program `s' l e4 1, 'ta Gila 43, +i r3?; «'� . jl 4' "� '� _ jA ro v : Lip.;. Try r ..t d,. , 1, `r i l S )-'^1
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- Public ED ': ow . .
Annual Report ._ ��.✓
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Documentationof
1. Line Clearing (1 O %) .
--° 2. High priority des (6
s)
Tit evc�3 ..i ;1..- !1 ¢�wti 1 � Q
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- 3. System observation annual
4. ROW mowing
r,?opr , Mp ' ye I
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Review logs for PS O&M
-0qe�'
P
eportable Spills
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epeat Location/Cause
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loom reportable spills n o y�
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er co
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Plaints 0 (40 w c r'
Spare parts inventory
Map of systelili % complete
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Pump Station Inspection Checklist
Name
Address
Housekeeping
Secure
Accessible
Identification Signage
Inspection Schedule Daily
Weekly
Wet Well — Floats
Free of debris ✓ )
High water float i (A" -
Telemetry ✓ /
Audio -Visual ✓ d/
SCADA
Alarm system tested for communications
No of Pumps 1
2
e✓
Operational 1
2
Capacity of each (gpm)
1
2
Runtime hour meter reading average
1
2
Emergency power Generator Portable Quick -connect _ nsite
Fuel tank let 0s / ( Gallons per hour usage rate
Testing schedule k i/ Automatic
Bypass pumping configurerd
Overflow piping
Manhole upstream
Inspection Logs

Collection System Inspection Checklist
Manholes- Lines- Right Of Way- Aerials
1. Manhole location or address
Cover present - vent and cover above grade - ventscreened
Visible signs of overflow
Sinkholes and depressions
Good condition properly seated
Bypass structures or pipes present
Invert in good condition Size / 0 inches Pipe capaci
Line free flowing and unrestricted I/
Excessive grease, roots, or sand
2. Right of Way - location or name of outfall line
Accessible
Free of sinkholes or depressions
No evidence of leakage
Free of non -utility motorized traffic
3. Aerials - High Priority lines
Exposed line of ductile material
Water crossings and supports in good condition
Level of debris on or behind line
Free of damage
Right of Way mowing records
Visual inspection of off street lines
General observation of system (annual)
diameter.

Name
Address
Pump Station Inspection 'Checklist
aol5
24-1y'S0
Housekeeping
Secure
Accessible t/
Identification Signage
Inspection Schedule Daily
Wet Well — Floats
Free of debris
High water float ✓/
Telemetry �,/
Audio -Visual
SCADA
Alarm _ -system tested for communications
Weekly
Emergency power
Fuel tank
Testing schedule
Bypass pumping co
Overflow piping
Manhole upstream
Inspection Logs
Generator
ti
of /<ed
c v',41a-c/t
Portable
Gallons per
Automatic
No of Pumps 1
2
Operational 1 a/
2i
Capacity of each (gpm)
1
2
Runtime hour meter reading' average
1
2
Quick -connect Onsite)
hour usage rate

Visible signs of overflow
Sinkholes and depressions
Good condition properly seated
Bypass structures or pipes present
Invert in good condition Size r
Line free flowing and unrestricted
Excessive grease, roots, or sand
1. Manhole location or address
Collection System Inspection Checklist
Manholes- Lines- Right Of Way- Aerials
SA, T
Cover present - vent and cover above gra le -vest-st
a/
t
%2 3/4 diameter.
inches Pige capaci
2. Right of Way - location or name of outfall line
Accessible
Free of sinkholes or depressions
No evidence of leakage
Free of non -utility motorized traffic
3. Aerials - High Priority lines
Exposed line of ductile material
Water crossings and supports in good condition
Level of debris on or behind line
Free of damage
Right of Way mowing records
Visual inspection of off street lines
General observation. of system (annual)

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--1. Number of Pump stations 5-, Z.
2. SCADA system P p
- 3. Telemetry PS 3
4, Audible and Visual only
5, Generators Permanent 5" 2,
a. Frequency tested wv.y..?-k y ram' v
.... Generators Portable N o of
- A. Quick -connect pink PS
B. Frequency tested
-Pump stations served by same generator.
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Ennforcemeuntts Last Year
FOG IProgra , ; .cA e4 « F ;,, , .
III
Inspections
Public ED How
Annual !': eport Date
oot Control Program
udget $
Years
Documentation of
1, Line Deal i inng (1O%)
2. High priority lines (6 m®s)
,ya c 11
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Reportable Sp
1111
epeat Locatio
s
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Customer complaints
Spare parts inventory
5
4; 6,..1
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----- Map of system % complete
al
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Pump Station Inspection Checklist
Name L 3 No of Pumps 1
2
Address 0 Operational 1
2
Capacity of each (gpm)
1
2
Runtime hour meter reading average
1.
2
Housekeeping ✓
Secure ✓
Accessible i✓ /
Identification Signage
Inspection Schedule Daily
Weekly
Wet Well — Floats V
Free of debris ✓
High water float
TelemeA C O
Audio- isual
SCADA
Alarm system tested for communications
Emergency power ox_9 Portable Quick -connect
Fuel tank Gallons per hour usage rate
Testing schedule Automatic
Bypass pumping configured
Overflow piping 9 et s—
Manhole upstream
Inspection Logs
„lav�,
— A cf CI n t Tc,J }1,
e.'-iiN��f= /
S h y1 ,c,_

1. Manhole location or address
Collection System Inspe Lion Checklist
Manholes- Lines- Right Of Way- Aerials
Cover present - vent and cover above grade - vent screened
Visible signs of overflow ✓l
Sinkholes and depressions
Good condition properly seated y
Bypass structures or pipes preset
-62
Invert in good conditionSize inches pe capaci �tfii/2 3/4 diameter.
Line free flowing and unfestrictedy
Excessive grease, roots, or sand vt
2. Right of Way - location or name of outfall line
c'Accessible r'
`Tree of sinkholes or depressions 4/
f/No evidence of leakage
Free of non -utility motorized traffic
3. Aerials - High Priority lines
Exposed line of ductile material
Water crossings and supports in good condition
Level of debris on or behind line
Free of damage
Right of Way mowing records
Visual inspection of off street lines
General observation of system (annual)

Pump Station Inspection Checklist
Name
Address
Housekeeping
Secure v�
Accessible
Identification Signage
Inspection Schedule Daily
�l
Weekly (/
No of Pumps 1
2
Operational 1
Capacity of each (gpm) r�� [2- "` l
1 parr
2
Runtime hour meter reading average
1•
2
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Free of debris e^—ao.s.— s % a I I o vct y, od d°,-[r ; ,,, e:1-'_,
High water float
Teleme �/✓ '` 5 `", a-i e�i��,— N `.5 �`,.s��, `��`�r,, J �, WA- n o �u�%/ tr',s
Audio"Visual SCADA Aa.b i.J._..- tP r$ kJ A.f/' u _ I
Alarm system tested for communications � �U �i
Emergency power Generator !/ Portable Quick -connect
Fuel tank Gallons per hour u ge rate
Testing schedule ✓✓.- .4337 Automatic
Bypass pumping configured
Overflow piping
Manhole upstream
Inspection Logs

Collection S stem Inspecti n Chec:, ist
�L,
ght Of Way- Aerials
Manholes- Lines-
1. Manhole location or address
r �
Cover present - vent and cover above grade - vent screened
Visible signs of overflow
Sinkholes and depressions vi
Good condition properly seated
Bypass structures or pipes present vi
Invert in good condition Size inches Pipe capacity 1/4 %2 3/4 diameter.
Line free flowing and unrestricted
Excessive grease, roots, or sand
2. Right of Way - location or name of outfall line
Accessible
Free of sinkholes or depressions
No evidence of leakage
Free of non -utility motorized traffic
. Aerials - High Priority lines
Exposed line of ductile material
Water crossings and supports in good condition
Level of debris on or behind line
Free of damage
Right of Way mowing records
Visual inspection of off street lines
General observation of system (annual)

Pat McCrory
Governor
ATA
NCDE R
North Carolina Department of Environment and Natural Resources
August 4, 2015
Mr. David Hux, Assistant Utilities Director
City of Shelby
Post Office Box 207
Shelby, North Carolina 28151-0207
Dear Mr. Hux:
Donald R. van der Vaart
Secretary
Subject: Compliance Evaluation Inspection
Town of Kingstown Collection System
Permit No. WQCSD0258
Kingstown, Cleveland County
Enclosed is a copy of the Compliance Evaluation Inspection Report for the inspection
conducted at the subject facility on July 30, 2015 by Mr. Barry Love and Mr. Ori Tuvia of this
Office. The assistance and cooperation of the staff there was greatly appreciated. The inspection
revealed that the system is being properly operated and well maintained.
The inspection report should be self-explanatory; however, should you have any questions
concerning this report, please do not hesitate to contact Mr. Love at [phone].
Michael L. Parker, Regional Supervisor
Mooresville Regional Office.
Water Quality Regional Operations Section
Division of Water Resources, NCDENR
Attachment: Inspection Report —July 2015
cc: Town of Kingstown
MRO file
PERCS
Mooresville Regional office, 610 East Center Avenue, Mooresville, North Carolina 28155
Phone: [phone]\ Internet: www,ncdenr.gov
An Equal Opportunity 1 Affirmative Action Employer — Made in part by recycled paper

4
Compliance Inspection Report
Permit: WQCSD0258 Effective: 07/06/07 Expiration:
SOC: Effective: Expiration:
County: Cleveland
Region: Mooresville
Contact Person: Clarence Withrow Title: Mayor
Directions to Facility:
System Classifications:
Primary ORC:
Secondary ORC(s):
On -Site Representative(s):
Related Permits:
Certification:
NC0024538 City of Shelby - First Broad River WWTP
Inspection Date: 07/30/2015
Owner : Town of Kingstown
Facility: Kingstown Collection System
Phone: [phone]
Phone:
Entry Time: 09:30AM Exit Time: 01:30PM
Primary Inspector: Barry F Love Phone: [phone] Ext.263
Secondary Inspector(s):
Ori A Tuvia
Reason for Inspection: Routine Inspection Type: Collection System Inspect Non Sampling
Permit Inspection Type: Deemed permitted collection system management and operation
Facility Status: jj Compliant El Not Compliant
Question Areas:
LJ
Miscellaneous Questions
® Records
Pump Station
(See attachment summary)
pri Performance Standards ® Operation & Maint Reqmts
Monitoring & Rpting Reqmts 11 Inspections
Manhole Lines
Page: 1

Permit: WQCSD0258 Owner - Facility: Town of Kingstown
Inspection Date: 07/30/2015
Inspection Type : Collection System Inspect Non Sampling
Reason for Visit: Routine
Inspection Summary:
Page: 2

Owner - Facility: Town of Kingstown
Permit: WQCSD0258
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What educational tools are used?
Flyers at various events and festivals in the area.
Is Sewer Use Ordinance/Legal Authority available?
Does it appear that the Sewer Use Ordinance is enforced?
Is Grease Trap Ordinance available?
Is Septic Tank Ordinance available (as applicable, i.e. annexation)
List enforcement actions by permittee, if any, in the last 12 months
Has an acceptable Capital Improvement Plan (CIP) been implemented?
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Is CIP designated only for wastewater collection and treatment?
Approximate capital improvement budget for collection system?
Total annual revenue for wastewater collection and treatment?
CIP Comments
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Is system free of known points of bypass?
If no, describe type of bypass and location
Is a 24-hour notification sign posted at ALL pump stations?
# Does the sign include:
Instructions for notification?
Pump station identifier?
24-hour contact numbers
If no, list deficient pump stations
# Do ALL pump stations have an "auto polling" feature/SCADA?
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Is a Spill Response Action Plan available?
What areas are scheduled for cleaning in the next 12 months?
Has at least 10% of system been cleaned annually?
Are system cleaning records available?
Are right-of-ways currently accessible in the event of an emergency?
Are maintenance records for right-of-ways available?
Inspecting alarms, telemetry and auxiliary equipment?
Inspecting and lubricating pumps and other equipment?
Inspecting and exercising all valves?
Inside and outside cleaning and debris removal?
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What is the schedule for testing emergency/standby equipment?
Is a schedule maintained for testing emergency/standby equipment?
Are maintenance records for equipment available?
What is the schedule for reviewing inspection, maintenance, & operations logs and problem areas?
Does the supervisor have plans to address documented short-term problem areas?
Does supervisor review all log books on a regular basis?
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Has there been visual inspections of high -priority lines in last six months?
Are records available that document inspections of high -priority lines?
# Has there been an observation of remote areas in the last year?
# Do you have a system to conduct an annual observation of entire system?
Are records available that document citizen complaints?
Are non-SCADA/telemetry equipped pump stations inspected every day?
Are SCADA or telemetry equipped pump stations inspected at least once a week?
Are records available that document pump station inspections?
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Are maintenance records for sewer lines available?
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Inspection Date: 07/30/2015
Inspection Type : Collection System Inspect Non Sampling
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Owner - Facility: Town of Kingstown

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Permit: WQCSD0258 Owner - Facility: Town of Kingstown
Inspection Date: 07/30/2015 Inspection Type : Collection System Inspect Non Sampling
Reason for Visit: Routine
Does the plan include:
24-hour contact numbers
Response time
Equipment list and spare parts inventory
Access to cleaning equipment
Access to construction crews, contractors, and/or engineers
Source of emergency funds
Site sanitation and cleanup materials
Post-overflow/spill assessment
Is a Spill Response Action Plan available for all personnel?
Is the spare parts inventory adequate?
Comment:
Records
Are adequate records of all SSOs, spills and complaints available?
Are records of SSOs that are under the reportable threshold available?
Do spill records indicate repeated overflows (2 or more in 12 months) at same location?
If yes, is there a corrective action plan?
Is a map of the system available?
Does the map include:
Pipe sizes
Pipe materials
Pipe location
Flow direction
Approximate pipe age
Number of service taps
Pump stations and capacity
If no, what percent is complete?
List any modifications and extensions that need to be added to the map
# Does the permittee have a copy of their permit?
Comment:
Monitoring and Reporting Requirements
Are copies of required press releases and distribution lists available?
Are public notices and proof of publication available?
# Is an annual report being prepared in accordance with G.S. 143-215.1C?
# Is permittee compliant with all compliance schedules in the permits?
If no, which one(s)?
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Page: 5

Owner - Facility: Town of Kingstown
Permit: WQCSD0258
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Reason for Visit:
Inspection Type : Collection System Inspect Non Sampling
Inspection Date: 07/30/2015
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Yes No NA NE
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Is the manhole free of visible signs of overflow?
Is the manhole free of sinkholes and depressions?
Is manhole cover present?
# Is manhole properly seated?
# Is manhole in good condition?
# Is invert in good condition?
s line free -flowing and unrestricted in manhole?
s manhole free of excessive amounts of grease?
s manhole free of excessive roots?
s manhole free of excessive sand?
s manhole's extended vent screened?
Are vents free of submergence?
Are manholes free of bypass structures or pipes?
Yes No NA NE
❑ ❑❑❑❑❑❑❑❑❑❑❑❑❑❑
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Is manhole accessible?
# Is manhole cover/vent above grade?
Is the manhole free of visible signs of overflow?
Is the manhole free of sinkholes and depressions?
Is manhole cover present?
# Is manhole properly seated?
# Is manhole in good condition?
# Is invert in good condition?
s line free -flowing and unrestricted in manhole?
s manhole free of excessive amounts of grease?
s manhole free of excessive roots?
s manhole free of excessive sand?
s manhole's extended vent screened?
Are vents free of submergence?
Are manholes free of bypass structures or pipes?

Permit: WQCSD0258 Owner - Facility: Town of Kingstown
Inspection Date: 07/30/2015 Inspection Type : Collection System Inspect Non Sampling Reason for Visit: Routine
Comment:
KINGSTOWN -
Lines/Right-of-Ways/Aerie) Lines
Is right-of-way accessible for emergency?
Is right-of-way free of sinkholes or depressions?
Is line/right-of-way free of evidence of leakage?
# Are there areas of exposed line?
# Is any exposed line constructed of ductile iron or other approved material?
Are water crossing and supports in good condition?
# Is right-of,way free of non -utility motorized traffic?
Is line free of visible damage?
# Are there siphons in this system?
If yes, are they maintained and documented?
ROW had been recently mowed.
Comment:
KINGSTOWN LS - 1623 W. -
Pump Station
Pump station type
Are pump station logs available?
Is it accessible in all weather conditions?
# Is general housekeeping acceptable?
Are all pumps present?
Are all pumps operable?
Are wet wells free of excessive debris?
Are upstream manholes free of excessive debris/signs of overflow?
Are floats/controls for pumps/alarms operable?
Is "auto polling" feature/SCADA present?
Is "auto polling" feature/SCADA operational?
Is simple telemetry present?
Is simple telemetry operational?
Are audio and visual alarms present?
Are audio and visual alarms operable?
Is the Pump station inspected as required?
Are backflow devices in place?
Are backflow devices operable?
Are air relief valves in place?
Yes No NA NE
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Page: 7

Permit: WQCSD0258
Owner - Facility: Town of Kingstown
Inspection Date: 07/30/2015 Inspection Type : Collection System Inspect Non Sampling
Reason for Visit: Routine
Are air relief valves operable?
# Is an emergency generator available?
Can the emergency generator run the pumps?
Is the pump station equipped for quick hook-up?
Is the generator operable?
# Is fuel in tank and sufficient?
Is the generator inspected according to their schedule?
Is a 24-hour notification sign posted?
Does it include:
Instructions for notification?
Pump station identifier?
Emergency phone number
Is public access limited?
Is pump station free of overflow piping?
Is the pump station free of signs of overflow?
Are run times comparable for multiple pumps?
Comment: Generator would not crank onthe day of the inspection. Records showed that it had been
operating recently through its weekly self test.
PETTY ROAD - 2015 Petty I
Pump Station
Pump station type.
Arepump station logs available?
Is it accessible in all weather conditions?
# Is general housekeeping acceptable?
Are all pumps present?
Are all pumps operable?
Are wet wells free of excessive debris?
Are upstream manholes free of excessive debris/signs of overflow?
Are floats/controls for pumps/alarms operable?
Is "auto polling" feature/SCADA present?
Is "auto polling" feature/SCADA operational?
Is simple telemetry present?
Is simple telemetry operational?
Are audio and visual alarms present?
Are audio and visual alarms operable?
Is the Pump station inspected as required?
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Duplex
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Page: 8

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no
Permit: WQCSD0258 Owner - Facility: Town of Kingstown
Inspection Date: 07/30/2015 Inspection Type : Collection System Inspect Non Sampling Reason for Visit: Routine
Are backflow devices in place?
Are backflow devices operable?
Are air relief valves in place?
Are air relief valves operable?
# Is an emergency generator available?
Can the emergency generator run the pumps?
Is the pump station equipped for quick hook-up?
Is the generator operable?
# Is fuel in tank and sufficient?
Is the generator inspected according to their schedule?,
Is a 24-hour notification sign posted?
Does it include:
Instructions for notification?
Pump station identifier?
Emergency phone number
Is public access limited?
Is pump station free of overflow piping?
Is the pump station free of signs of overflow?
Are run times comparable for multiple pumps?
Comment: Pump one had been out for repair recently. It had not been reset to auto rotate, so didn't show a
change in run time.
Page: 9

Beverly Eaves Perdue
Governor
NCDEHR
North Carolina Department of Environment and Natural Resources
FILE„-
Division of Water Quality
Coleen H. Sullins Dee Freeman
Director Secretary
August 22, 2011
Mr. Brad Cornwell, Public Utilities Director
City of Shelby
P. O. Box 207
Shelby, NC 28151
Subject: Notice of Violation
Tracking No. NOV-2011-DV-0210
Collection System Permit
Number WQCSD0258
Town of Kingstown
Cleveland County
Dear Mr. Cornwell:
A review has been conducted of the Town of Kingstown's self reported Sanitary Sewer
Overflows (SSOs) 5-Day Report(s) for July 2011. This review has shown Kingstown to be in
violation of the requirements found in Collection System Permit WQCSD0258 and/or G.S. 143-
215.1(a)(1). The violations that occurred during July 2011 are summarized in Attachment A.
Remedial and corrective actions, if not already implemented, should be taken to prevent
further SSOs. As of December 1, 2007, any reportable SSO may be issued a Notice of Violation
(NOV) and some may be assessed a civil penalty. Civil penalties will be issued for SSOs based
on volume, volume reaching surface waters, duration and gravity, impacts to public health, fish
kills, and recreational area closures. Other factors considered in determining the amount of the
civil penalty are the violator's history of spills, the cost of rectifying the damage, whether the
spill was intentional, and whether money was saved by non-compliance.
Mooresville Regional Office
Location: 610 East Center Ave., Suite 301 Mooresville, NC 28115
Phone: [phone] \ Fax: [phone] \ Customer Service: 1-877-623-6748
Internet: www.ncwaterquality.org
An Equal Opportunity \ Affirmative Action Employer — 50% Recycled/10% Post Consumer paper
One
NorthCarolina
A atffralll/

Mr. Brad Cornwell
NOV-201 1-DV-0210
Page 2
Be advised that G.S. 143-215.6A provides for a civil penalty assessment of not more than
twenty-five thousand dollars ($25,000), or twenty-five thousand dollars ($25,000) per day when the
violation is of a continuing nature, against any person who is required but fails to apply for or to
secure a permit required by G.S. 143-215.1. Penalties may also be assessed for any damage to the
surface waters of the State that may result from the unpermitted discharge.
The SSOs noted in Attachment A under violation action as "Proceed to Enforcement" are
the overflows that the regional office has determined, after review of the CS-SSO 5-day report,
that may result in a civil penalty assessment. You have 20 days from receiving this Notice of
Violation letter to provide any additional justification for the identified SSOs as to why
these spills do not meet the criteria listed in this letter for civil penalty assessment.
If you have any questions regarding this policy please do not hesitate to contact Mr. Lon
Snider or myself at 704-663-1699.
Sincerely,
Robert B. Krebs
Surface Water Protection Section Supervisor
Division of Water Quality
Mooresville Regional Office
Attachment — A
Cc: PERCS Files

Attachment A
Town of Kingstown Collection System
July 2011
24 Hour 5 Day Vol.
Cause:
Pemlit # Location Incident # Start Date Gallons Reaching Surface NOV Case Violation Action Cause: Grease
Water Debris in line
WQCSD0258 Quail Run Dr ROW 20110/339 07/01/11 1270 318 NOV-2011-DV-0210 Proceed to NOV Yes Yes

•
FiLEks
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Ccieen H. Sullins Dee Freeman
Governor Director Secretary
December 15, 2010
Mr. David Hux, Assistant Public Works Director
City of Shelby
P. O. Box 207
Shelby, NC 28151
Subject: Compliance Evaluation Inspection
Town of Kingstown Collection System
Deemed Permit No. WQCSD0258
Cleveland County, N.C.
Dear Mr. Hux:
Enclosed is a copy of the Compliance Evaluation Inspection Report for the inspection
conducted at the subject facility on December 1, 2010 by Mr. Lon Snider of this Office. The
operation and maintenance activities initiated by the facility staff are commendable.
The report should be self-explanatory; however, should you have any questions
concerning this report, please do not hesitate to contact Mr. Snider at [phone].
Sincerely,
Robert B. Krebs
Surface Water Protection Regional Supervisor
Enclosure
cc: Town of Kingstown
Mooresville Regional Office
Location: 610 East Center Ave., Suite 301 Mooresville, NC 28115
Phone: [phone] \ Fax: [phone] Customer Service: 1-877-623-6748
Internet: www.ncwaterquality.org
An Equal Opportunity \ Affirmative Action Employer — 50% Recycled/10% Post Consumer paper
NorthCarolina
Naturally

f
Compliance Inspection Report
Permit: WQCSD0258 Effective: 07/06/07 Expiration:
SOC: Effective: Expiration:
County: Cleveland
Region: Mooresville
Contact Person: Clarence Withrcw
Directions to Facility:
Owner: Town of Kingstown
Facility: Kingstown Collection System
Title: Mayor Phone: [phone]
System Classifications:
Primary ORC: Certification: Phone:
Secondary ORC(s):
On -Site Representative(s):
Related Permits:
NC0024538 City of Shelby - First Broad River WNTP
Inspection Date: 12/01/2010Entry Time: 09:00 AM Exit Time: 03:00 PM
Primary Inspector: Lon Snider
Secondary Inspector(s):
Phone: [phone]
Reason for Inspection: Routine Inspection Type: Collection System Inspect Non Sampling
Permit Inspection Type: Deemed permitted collection system management and
operation
Facility Status: El Compliant ❑ Not Compliant
Question Areas:
El Miscellaneous Questions
Monitoring & Rpting
Reqmts
Lines
Performance Standards
Inspections
(See attachment summary)
rai Operation & Maint Regmts Records
Ei Pump Station Manhole
Page: 1

Inspection Date: 12/01/2010
Permit: VVQCSD0258 Owner - Facility: Town of Kingstown
Inspection Type: Collection System Inspect Non Sampling Reason for Visit: Routine
Inspection Summary:
Page: 2

Permit: WQCSCO258 Owner - Facility: Town of Kingstown
Inspection Date: 12/01/2010 Inspection Type: Collection System Inspect Non Sampling
Reason for Visit: Routine
Performance Standards
Is Public Education Program for grease established and documented?
'Nrat educational tools are used?
Mailers.
Is Sewer Use Ordinance/Legal Authority available?
Does it appear that the Sewer Use Ordinance is enforced?
Is Grease Trap Ordinance available?
Is Septic Tank Ordinance available (as applicable, i.e. annexation)
List enforcement actions by permittee, if any, in the last 12 months
None
Has an acceptable Capital Improvement Plan (CIP) been implemented?
Does CIP address short term needs and long term \"master plan\" concepts?
Does CIP cover three to five year period?
Dees CIP include Goal Statement?
Does CIP include description of project area?
Does CIP include description of existing facilities?
Does CIP include known deficiencies?
Does CIP include forecasted future needs?
Is CIP designated only for wastewater collection and treatment?
Approximate capital improvement budget for collection system?
Total annual revenue for wastewater collection and treatment?
CIP Comments
Is system free of known points of bypass?
If no, describe type of bypass and location
Is a 24-hour notification sign posted at ALL pump stations?
# Does the sign include:
Instructions for notification?
Pump station identifier?
24-hour contact numbers
If no, list deficient pump stations
Yes No NA NE
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Page: 3

Permit: WQCSD0258 Owner - Facility: Town of Kingstown
Inspection Date: 12/01/2010
Inspection Type: Collection System Inspect Non Sampling Reason for Visit: Routine
# Do ALL pump stations have an "auto polling" feature/SCADA?
Number of pump stations
Number of pump stations that have SCADA
Number of pump stations that have simple telemetry
Number of pump stations that have only audible and visual alarms
Number of pump stations that do not meet permit requirements
# Does the permittee have a root control program?
# If yes, date implemented?
Describe:
Pump Stations have simple telemetry.
Comment:
Inspections
Are maintenance records for sewer lines available?
Are records available that document pump station inspections?
Are SCADA or telemetry equipped pump stations inspected at least once a week?
Are non-SCADA/telemetry equipped pump stations inspected every day?
Are records available that document citizen complaints?
# Do you have a system to conduct an annual observation of entire system?
.# Has there been an observation of remote areas in the last year?
Are records available that document inspections of high -priority lines?
Has there been visual inspections of high -priority lines in last six months?
Comment:
Operation & Maintenance Requirements
Are all log books available?
Does supervisor review all log books on a regular basis?
Does the supervisor have plans to address documented short-term problem areas?
What is the schedule for reviewing inspection, maintenance, & operations logs and problem areas?
Weekly.
Are maintenance records for equipment available?
Is a schedule maintained for testing emergency/standby equipment?
What is the schedule for testing emergency/standby equipment'?
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Yes No NA NE
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Weekly
Page: 4

Permit: WCCSD0258 Owner - Facility: Town of Kingstown
Inspection Date: 12/01/2010
Inspection Type: Collection System Inspect Non Sampling Reason for Visit: Routine
Do pump station logs include:
Inside and outside cleaning and debris removal?
Inspecting and exercising all valves?
Inspecting and lubricating pumps and other equipment?
Inspecting alarms, telemetry and auxiliary equipment?
Is there at least one spare pump for each pump station w/o pump reliability?
Are maintenance records for right-of-ways available?
Are right-of-ways currently accessible in the event of an emergency?
• Are system cleaning records available?
Has at least 10% of system been cleaned annually?
What areas are scheduled for cleaning in the next 12 months?
N/A
Is a Spill Response Action Plan available?
Does the plan include:
24-hour contact numbers
Response time
Equipment list and spare parts inventory
Access to cleaning equipment
Access to construction crews, contractors, and/or engineers
Source of emergency funds
Site sanitation and cleanup materials
Post-overflow/spill assessment
Is a Spill Response Action Plan available for all personnel?
Is the spare parts inventory adequate?
Comment:
Records
Are adequate records of all SSOs, spills and complaints available?
Are records of SSOs that are under the reportable threshold available?
Do spill records indicate repeated overflows (2 or more in 12 months) at same location?
If yes, is there a corrective action plan?
Is a map of the system available?
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Page: 5

t
Permit: WQCSD0258 Owner - Facility: Town of Kingstown
Inspection Date: 12/01/2010
Inspection Type: Collection System Inspect Non Sampling Reason for Visit: Routine
Does the map include:
Pipe sizes
Pipe materials
Pipe Iccaticn
Flow direction
Approximate pipe age
Number of service taps
Pump stations and capacity
If no, what percent is complete?
List any modifications and extensions that need to be added to the map
# Does the permittee have a copy of their permit?
Comment:
Monitoring and Reporting Requirements
Are copies of required press releases and distribution lists available?
Are public notices and proof of publication available?
# Is an annual report being prepared in accordance with G.S. 143-215.1C?
# Is permittee compliant with all compliance schedules in the permits?
If no, which one(s)?
Comment: Kingston Deemed Collection System is operated by the City of Shelby.
KINGSTOWN - 1623 Zion Church Road
Pump Station
Pump station type
Are pump station logs available?
Is it accessible in all weather conditions?
# Is general housekeeping acceptable?
Are all pumps present?
Are all pumps operable?
Are wet wells free of excessive debris?
Are upstream manholes free of excessive debris/signs of overflow?
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Yes No NA NE
Duplex
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Page: 6

Permit: WGCSCO258 Owner - Facility: Town of Kingstown
Inspection Date: 12/01/2010 Inspection Type: Collection System Inspect Non Sampling
Are floats/controls for pumps/alarms operable'?
Is "auto polling" feature/SCADA present?
Is "auto polling" feature/SCADA operational?
Is simple telemetry present?
Is simple telemetry operational?
Are audio and visual alarms present'?
Are audio.and visual alarms operable?
Is the Pump station inspected as required?
Are backflow devices in place?
Are backflow devices operable?
Are air relief valves in place?
Are air relief valves operable?
# Is an emergency generator available?
Can the emergency generator run the pumps?
Is the pump station equipped for quick hook-up?
Is.the generator operable?
# Is fuel in tank and sufficient?
Is the generator inspected according to their schedule?
Is a 24-hour notification sign posted?
Does it include:
Instructions for notification?
Pump station identifier?
Emergency phone number
Is public access limited?
Is pump station free of overflow piping?
Is the pump station free of signs of overflow?
Are run times comparable for multiple pumps'?
Reason for Visit: Routine
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Comment: This is Kingston's main pump station that sends all of its flow to the City of
Shelby.
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5-10 hours per week
Page: 7

Collection System SSO 24-Hour Notification
Collection System: Number and Name VVQCV OZS S
Incident Number from BIIVIS CD(IDI �c(
Incident Reviewed (Date):
Incident Action Taken: J
NOV-2011-DV
CORAO
1 d C C A R 6 72L O H@ S■ a e 222 626•®■ C C 6@ ®E ®® F 9■ H 8 Y 6 C O B® A O E H 6 6 m C 9 1•2 H 0 9 Y 6 9 G E R! 0 e e u c s a
(1.cam
Spill Date ( Time calm/ pm
Reported Date 7i( Time tAc am/isao
Reported To SWP Staff or EM Staff (—ors SN► ref
Reported By
-(9
Phone 70Lt
Address of Spill a_, A gr- 2 c -
County City (/_,,sss(--evz
Cause of Spill C,,e, }-
Total Estimated Gallons
14270 Est. Gal to Stream 3 I
Strearn r;(2 kusL3 CI Fish Kill: Yes No Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

07/06/2011 09:04 704-484-6808
CITY OF SHELBY UDC
PAGE 02
Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
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 Nurriber : WQCSD0258
To'mi of Kingstown
Facility:
Town of Kingetown
Owner.
City: Kingaton, NC
(WQCS# if active, otherwise use treatment plant NC/W 01 \ 3 rC\
Incident #
Source of S50 (check applicable) :
❑✓ Sanitary Sewer
© Pump Station
Region:
County
Mooresville
clevelend
SPECIFIC location of the SSO (be consistent in description from past reports or documentation - i,e. Pump Station 6,
Manhole 10060803
Manhole at Westall & Bragg Street, etc.) :
Latitude (degrees/minute/second):
Incident Started Dt: 07 01 2011
(mm-dd-yyyy)
1,270
Estimated volume of the SSO:
Time. 10:00 am
hh:mm AM/PM
Describe how the volume was determined:
Weather conditions during SSO event: Hotenddry
Did SSO reach surface waters? 0 Yes❑NoE1 Unknown
Surface water name; Unnamed tributary of Brushy Creek
Did the SSO result in a fish kill? ❑ Yes
SPECIFIC cause(s) of the SSO;
TD Severe Natural Condition
El inflow and Infiltration
❑ Vandalism
gallons
Longitude(degrees/minute/second):
07-01 2011 11:00 am
Incident End Dt Time:
(mm-dd-yyyy) hh:mm AM/PM
Estimated Duration (Round to nearest hour):
8" pipe=1/10=(400)^1/5(1670)=1270X1hr.1270x25%=318 gals
Volume reaching surface waters (gallons): 318
�✓ No ❑ Unknown If Yes, what is the estimated number of fish killed?
Immediate 24-hour verbal notification reported to:
r`
❑� Grease
❑ Pump Station Equipment Failure
E✓ Debris in line
Lon Snider
❑ Roots
C Power outage
❑ Other (Please explain in Part II)
DWQ Emergency Mgmt. Date (mm-dd-yyyy): 07-01-2011 Time (hh:mm AM/PM): 1:45 pm
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the discharge occurred, When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 1 D 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 re uired to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control,
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003 Page 1

07/06/2011 09:04 70d-484-6808 CITY OF SHELBY UOC
PAGE 01
Shel. -,..„-
NORTH CAR.Ot,tNA
Post Office 13ax 207 Shelby, NC 20151-0Z07
Fax Transmission Cove- Sheet
To:
Lon Snider From: Karen Wilkins
Company: NC DWQ
Date: 7/6/2011
Fax:
704.663.6040 Dept: Utilities
Phone: [phone]
Re: Spill Report - Quail Run Dr
Message:
Following is our report for the Quail Run Dr spill reported on July 1, 2011.
.Number- of pees transmitted (including cover sheet) 9
If you do not receive all the pages, please call 704,484.6840
Revfsed 3/2008
www_cityofshelby.com

07/06/2011 09:04 704-484-6808
CITY OF SHELBY UOC PAGE 03
Farm CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
PART 1 I
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN PART I OF THIS FORM
AND INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTIONS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN PART I
In the check boxes below, NA = Not Applicable and NE = Not Evaluated
A HARDCOPY OF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWQ REGIONAL OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Severe Natural Condition (hurricane, tornado, etc.)
Describe the "severe natural condition" in detail.
How much advance warning did you have and what actions were taken in preparation for the event?
Comments'
Grease (Documentation such as cleaning, inspections, enforcem ent
actions, past overflow reports, educational material and distribution date
etc. should be available upon request.)
When was the last time this specific line (or wet well) was cleaned?
Do you have an enforceable grease ordinance that requires new or retrofit of grease traps/interceptors?
Have there been recent inspections and/or enforcement actions taken on nearby restaurants or other.
nonresidential grease contributors?
Explain.
No restaurants
EJYesLJ No❑NAONE
Yes❑ No E NA ❑ NE
Have there been other SSOs or blockages in this area that were also caused by grease? ❑YesErNo El NA ❑NE
When?
If yes, describe them:
Have cleaning and inspections ever been increased at this location?
Explain_
❑Yes No❑NA❑NE
CS-SSO Form October 9. 2003
Page 2

07/06/2011 09:04 704-484-6808
CITY OF SHELBY UOC PAGE 04
Have educational materials about grease been distributed in the past? ❑Yesl--U No ❑ NA u NE
When?
and to whom?
Explain?
If the SSO occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation?
Were the floats clean?
Comments:
OYEZ) No❑NAQNE
Roots
Do you have an active root control program?
Describe
❑ YesD No ❑ NA ❑ NE
Have cleaning and inspections ever been increased at this location because of roots?
Explain_
L1YeJIIl NoLNALJNE
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? ilYe
If Yes, when?
Comments:
NoNA❑NE
Inflow and Infiltration ��yy T 1 d�I
Are you under an SOC (Special Order by Consent) or do you have a schedule in any permit that &--1 Ye.� l No DNA UNE
addresses UI?
CS-SSO form October 9, 2003 Page 3

07/06/2011 09:04 704-484-6808
CITY OF SHELBY UOC PAGE 05
Explain if Yes:
What corrective actions have been taken to reduce or eliminate I & I related overflows at this spill location
within the last year? 1--c
Has there been any flow studies to determine I/1 problems in the collection system at the SSO location? YeE No DNAONE
ONE
If Yes, when was the study completed and what actions did it recommend?
Has the line been smoke tested orvideoed within the past year? ❑YesO No CNA ENE
If Yes, when and indicate what actions are necessary and the status of such actions:
Are there I/I related projects in your Capital Improvement Plan?
If Yes, explain:
Yes0 No NA
Have there been any grant or loan applications for 1/1 reduction projects? flYasin No IJNA DNE
If Yes, explain: Do you suspect any major sources of inflow or cross connections with storm sewers? ❑Yes —
No ENA ®NE
If Yes, explain: -� �l
Have all lutes contacting surface waters in the SSO location and upstream been inspected recently? ElYen NoCNA ENE
If Yes, explain:
What other corrective action9 are planned to prevent future I/1 related SSOe et this location?
Comments:
Pump Station Equipment Failure (Documentation of testing, records etc.,
shoul be provided upon request.)
What kind of notification/alarm systems are present?
Auto-dialer/telemetry (one-way communication) ❑Yee
CS-SSO Fonn October 9, 2003
Page 4

07/06/2011 09:04 704-484-6808
CITY OF SHELBY UOC PAGE 06
Audible 1JYes
❑Yes
Visual
SCADA (two-way communication) l_lYes
Emergency Contact Signage Yes
❑Yes
Other
Describe the equipment that failed?
What kind Of situations trigger an alarm condition at this station (i.e. pump failure, power failure, high
water, etc.)?
Ware notification/alarm systems operable?
If no, explain:
❑YesEll No UNA TINE
If a pump failed, when was the last maintenance and/or inspection performed?
What specifically was checked/maintained?
If a valve failed, when was it last exercised'?
Were all pumps set to alternate?
Did any pump show above normal run times prior to and during the SSO event?
Were adequate spare parts on hand to fix the equipment (switch, fuse, valve, seal, etc.)?
Was a spare or portable pump immediately available?
If a float ptoblern, when were the floats last tested? Haw?
❑Yes No ❑NA❑NE
CI Yes® NoGNAEINE
❑YeFV I No NA CI NE
EllYesO No❑NADNE
If an auto=dialer or SCADA, when was the system last tested? How'?
Comments:
CS-SSO Form October 9, 2003 Page 5

mit
07/06/2011 09:04 704-484-6808
CITY OF SHELBY UOC PAGE 07
Power outage (Documentation of testing records, etc., should be
provided of alternative power source upon request.)
What is your alternate power or pumping source?
Or-`.Slito :GeberatorifidAT
Did it function properly?
Describe?
When was the alternate power or pumping source last tested under load?
❑YesIL I No CNA ONE
If caused by a weather event, how much advance warning did you have and what actions were taken to
prepare for the event?
Comments:
Vandalism
Provide police report number:
Was the site secured?"
if YP4 hr.nr7
Padlocked Control Panel
CDYesu NOENADNE
Have there been previous problems with vandalism at the SSO location?
If Yes, explain:
NA NE
What security measures have been put in place to prevent similar occurrences in the future? ]Yesd No NA UNE
Comments:
Debris in line (Rocks, sticks, rags and other items not allowed in the
collection system, etc,)
What type of debris has been found in the litre?
Sticks
How could it have gotten there?
Had to be placed into system through vent holes in lid.
Are manholes in the area secure and intact?
UyesLJ NoL
NA ®NE
CS-SSO Form October 9, 2003
Page 6

07/06/2011 09:04 704-484-6808
CITY OF SHELBY UOC PAGE 08
When was the area last checked/cleaned?
Have cleaning and inspections ever been increased at this location due to previous problems with debris? °YesEl No LNAClNE
Explain: •
Are appropriate educational materials being developed and distributed to prevent future similar
occurrences?
Comments:
YesNoDNA UNE
Other (Pictures and a police report should be available upon request.)
Describe:
Were adequate equipment and resources available to fix the problem? DYe
If Yes, explain:
No _ NA ©NE
If the problem could not be immediately repaired, What actions were taken to lessen the impact of the
SSO?
Comments:
For DWQ Use Only:
DWQ Requested an Additional Written Report:
If Yes, What Additional Information Is Needed:
DyesL No DNA u NE
Comments:
CS-SSO Form October 9, 2003 Page 7

07/06/2011 09:04 704-484-6808
CITY OF SHELBY UDC
PAGE 09
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: Mark Swink
Signature:
Date: 7/6/11
Field Operations Superintendent
Title:
Telephone Number: 704-484-6840
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five days of first
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of this form
is completed, if used).
CS-SSO Form October 9, 200
Page 8