WQCS00233_Regional Office Historical File Pre 2018 (3)

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#
cc
Incident Number from BIMS(0 960' c47
Incident Reviewed (Date):
Incident Action Taken: BPJ
/"NOV-2009-DV O ? 1
Spill Date AN
Reported Date 1q/OC?
Time
Time
Reported To SWP Staff or EM Staff ( YY\
Reported By 4d° /1( iGtill6t05
Address of Spill - 1-1 CP 1C/
0
County a/ui -, Co City
rr
Cause of Spill
Total Estimated Gallons 606 Est. Gal to Stream
Stream 6-bCt(J ' Fish Kill: Yes Number Species
Phone
`44-11(-)
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad
ini/ 7 Y4/77
A 0 Lia

1
F E B 1 7 ri3 Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
PART 1
This form shall be submitted t:NORIErpri*Oe:Pyt t )f ( nNithin five daysof the first knowledge of
the sanitary sewer overflow (SPIOY.0 Uul
O
WQCSOO233
Permit Number : ��° �'�j 3.�Q 1
(WQCS# if active, otherwise use treatment plant NCNVQ#)
Facility: I4e"iRY _
Owner: ()T! 0Ti S, Luc_ Crn Lmlt3- f1L)5764 5L OF Aid -
City. ,.24JD/i9-00 /sir',9/ L j 4) C'—
Incident #
Region:
County:
0 GU/OAJ
Source of SSO (check applicable) : 0 Sanitary Sewer 0 Pump Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation - i.e. Pump Station 6,
Manhole at Westall & Bragg Street, etc) ' 14410}foLP # 57 (6A3 14 EM/ Ya ZP
Latitude (degrees/minute/second):
Incident Started Dt: _ _ U�
Time: go: ✓✓ Incident End Dt U2 —e)Y—©i
Long itude(deg rees/minute/second)'
(mm-dd-yyyy) hh:mm AM/PM (mm-dd-yyyy)
Estimated volume of the SSO:
Time' gt9C-nvi
hh:mm AM/PM
900 gallons Estimated Duration (Round to nearest hour): 3
Describe how the volume was determined: l5-019 - 0135&P'L /1176A.f
Weather conditions during SSO event:
©,C k2ow ij9 TE K 7MF
Did SSO reach surface waters? Yes❑No❑ Unknown
Surface water name: Nvr Fa,-4 Cr" kec( Creek -
Did the SSO result in a fish kill? D Yeslo ❑ Unknown
SPECIFIC cause(s) of the SSO:
❑ Severe Natural Condition
❑ Inflow and Infiltration
❑ Vandalism
Immediate 24-hour verbal notification reported to:
DWQ ❑ Emergency Mgmt.
Volume reaching surface waters (gallons): 700
If Yes, what is the estimated number of fish killed?
❑ Grease
❑ Pump Station Equipment Failure
Debris in line I J _
co�/ / M t rrr s ++
Date (mm-dd-yyyy): 2. 9 • o S
❑ Roots
CI Power outage
❑ Other (Please explain in Part II)
Time (hh:mm AM/PM): 2: 1 3 P4/
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general.
coverage in the county where the discharge. occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible altematives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part 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 11 IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form October 9, 2003
Page 1

r
1

Debris in line (Rocks, sticks, rags and other items not allowed in the collection system, etc.)
What type of debris has been found in the line?
p 65 / ,4),-, j & M6h/&J p J r'U 5
Suspected cause or source of debris.
,g-L--05 E-v DDlvLS 7 J/ 73
Are manholes in the area secure and intact? n Ye9X No n NA 11 NE
When was the area last checked/cleaned?
Have cleaning and inspections ever been increased at this location due to previous problems with debris? n
Explain:
nNAnNE
Are appropriate educational materials being developed and distributed to prevent future similar n Yell No n NAn NE
occurrences?
Comments:
CS-SSO Form Page 11

Other (Pictures and police report, as applicable, must be available upon request.)
Describe:
Were adequate equipment and resources available to fix the problem? Yes. No ❑ NAD I NE
If Yes, explain: 6_0u 7 /g (Y-TQ Lee9' ieP OV'/)J W 1711 d ET ZRc,cK.
ti/A-d i 2inei)_ _ &-u_i 2 C--22X) 5
If the problem could not be immediately repaired, what actions were taken to lessen the impact of the
SSO?
Comments:
CS-SSO Form Page 12

•
System Visitation
ORC
Backup
Name: Pc A - e 4/@x 94 eI C C
Cert# qc1) ias7
Date visited:
Time visited:
28--09
30- .goo fen
0Yes
El Yes
How was the SSO remediated (i.e. Stopped and cleaned up)? 172,9/iv w 9-S 4C27-6D re) � e'6-'
J Ml'\6-D /11- EL}' cbAoPP z d3ECoeci 14fi31JF
As a representative for the responsible party, I certify that the information contained in this report is true and accurate to
the best of my knowledge.
Person submitting claim:
La d41�i�c-�
Signature: ��, 1
Telephone Number:
20 y 5A5— 79.0
Date: ?, — / O 0
Title:
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five days of first
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of this
form is completed, if used).
CS-SSO Form Page 15

RECEIVED
DIVISION OF,WATER QUALITY
SEP 21 2012
,,c‘„skft-d4r"
Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
ST>Pis .CTION
MOORESVILLE REGIONAL OFFICE
V 112009 PART
This form shall be submitted.to the appropriate DWQ Regional Office within five days
the sanitary sewer overflow (SSO).
: CS 33 (WQCS# if active, otherwise use WQCSD#)
ei / riP Incident #
0/ 2 � �A,9 �A/a TPr S'e f L" C E'�✓VC _ Region. /yc5,2/' 6?-5 1/-1 /7
/l/C/ / /-7�1/ ��G / r Z/,,?// o/v
Number
Permit
Facility:
Owner
City:
Source of SSO (check applicable) : IB Sanitary Sewer
SPECIFIC location of the SSO (be consistent in description from
Manhole at Westall & Bragg Street etc.) M y,7n /Q
Manhole# g f
Latitude (degrees/minute/second).
Incident Started Dt:
(mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO:. '� 0 gallons
/.° 310
❑ Pump Station / Lift Station
_past reports or documentation - i.e. Pump Station 6,
7- i/ ��.,i /4J,/�../FZ—eP- ,liv
of the first knowledge of
County:
O? /6-"2Time:
Describe how the volume was determined:
Weather conditions during SSO event: ��5 (-// /ty ��'
Did SSO reach surface waters? 0 Yes tJNoO Unknown Volume reaching surface waters (gallo
Surface water name. /LA >"`e
Did the SSO result in a fish kill? 0 Yes Nob Unknown
SPECIFIC cause(s) of the SSO:
0 Severe Natural Condition 0 Grease
❑ Inflow and Infiltration 0 Pump Station Equipment Failure
❑ Vandalism Debris in line
❑ Pipe Failure (Break)
24- r verbal notification (name of person contacted)
DWQ Emergency Mgmt.
Longitude(deg rees/minute/second)
Incident End Dt: C)42'-//n-/2 Time /6' 3o
hh:mm AM/PM
3 ti/-5
.(mm-dd-yyyy)
Estimated Duration (Round to nearest hour).
%9AL /tea c//e4./4i .fiver 1, ',ba S
If Yes, what is the estimated number of fish killed?
qit
❑ Roots
0 Power outage
❑ Other (Please explain in Part II)
L/ /R /91/
Date (mm-dd-yyyy) 9-a Zoh-
Time (hh:mm AM/PM). R: Z5,42,1'+
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the aischarge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form Page 1

Debris in line (Rocks, sticks, rags and other items not allowed in the collection system, etc.)
What type of debris has been found in the li e?
v c 4,7 I f9(///) K7,91/e/
Suspected cause or source of debris.
Are manholes in the area secure and intact?
When was the area last checked/cleaned?
ea No ❑ NA❑ NE
/9/ la/2-
Have cleaning and inspections ever been increased at this location due to previous problems with debris? 0 Ye No ❑ NAQ NE
Explain:
Are appropriate educational materials being developed and distributed to prevent future similar ❑ Yea No aliZ NE
occurrences?
Comments:
CS-SSO Form
Page 11

Other (Pictures and police report, as applicable, must be available upon request.)
Desc��riAAbe: A,,90/
// //
Were adequate equipment and resources available to fix the problem? YeCI No NAD NE
If Yes, explain:
>� G I% L Tr iv c/� o eN A/C e7 i% 5-ea,e e%ve
l� ti9�
If the problem could not be immediately repaired, what actin s were taken to lessen the impact of the
SSO?
Comments:
CS-SSO Form
Page 12

System Visitation
ORC
Yes
v
Backup D Yes
Name: 1.A C(lj lie Av cr
Cert# Lv/�cfiu.4, .14
Date visited: ?-/6 - ( .
Time visited:
/300
How was the SSO remediated (i.e. Stopped and cleaned up)?
TAQ i ve kvitS )e H a/aA OL&Aiec�l . r4, 5p� /r,�i4S Sve.�Pc.% 4,0„,„r74-rvcAiax,,p/x6,re,,
WAS iwk-e IGPof OrECc4✓ wit -/loN •
As a representative for the responsible party, I certify that the information contained in this report is true and accurate to
the best of my knowledge.
Person submitting claim:
Signature:
/1'7
Telephone Number: 70 y- 376 -
Title:
Date: I.- /2,
D,/,.-rcc 7)
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five days of first
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of this
form is completed, if used).
CS-SSO Form Page 15

North Carolina Emergency Management - EM43 Reporting Page 1 of 3
North Carolina Emergency Management - EM43 Reporting
Print
Return To List
EM Level:
4
Taken by:
cletourneau
Reported by:
Larry Henry
County:
Mecklenburg
Street Address:
Henry Acres Subdivision
Type: Wastewater
Animal Disease Event Type:
Complaint Event Type:
FNF Event Type:
HazMat Event Type:
Homeland Security Event:
Other Event Type:
Transportation Event Type:
Weather Event Type:
State Resource Request
NCEM Edited:
Yes
Date/Time Reported:
09/16/2012 15:19:37
Agency:
Local Utilities
City:
Charlotte
EVENT TYPE
Bomb Threat Event Type:
Fire Event Type:
FNF Class:
HazMat Class:
Non-FNF Event:
SAR Type:
Wastewater Event Type:
Sewage
Weather Event Name:
Include in Report:
Yes
Date/Time Occurred:
09/16/2012 15:19:37
Phone:.
7043610641
Area:
13
Zip Code:
HazMat Mode:
Non-FNF Event Type:
WMD Event Type:
Event Description:
Local Utilities reported a sewage release of 200 gallons due to debris in the line. The release was
contained to a nearby ditch. Clean up was conducted.
Filename:
Deaths:
0
Responsible Party:
Point of Contact:
Latitude:
00.000000
RRT Request:
Injuries:
0
RRT Approved:
Evacuation:
0
Responsible Party Phone:
Point of Contact Phone:
Longitude:
-00.000000
RRT Team
Number:
Radius:
0
RRT Mission
Number:
https://www.ncsparta.net/eoc7/boards/board.aspx?tableid=275&viewid=1011 &uvid=1.3 83... 9/17/2012

a . vVJ`l�%r4
✓ �G
SWP SECTION
'MOORESVILLEiREGIONALDF,FI.DE
R
E tivisiON OF WATEECEIVEDR QUALITY
AUG 072012
Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
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 : NC0035041
Facility:
Owner:
City:
EACS
Hemby Acres
Carolina Water Service Inc of NC
233
(WQCS# if active, otherwise use treatment plant NC/WQ#)
Incident #
Charlotte, NC
Source of SSO (check applicable) :
✓❑ Sanitary Sewer
Pump Station
Mooresville
Region:
County: Union
SPECIFIC location of the SSO (be consistent in description from past reports or documentation - i.e. Pump Station 6,
Manhole at Westall & Bragg Street, etc) ; Manhole # 5 (5811 Hillcrest Circle)
Latitude (degrees/minute/second):
Incident Started Dt: 08-02-2012 Time. 7:30 pm
(mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO: 600 gallons
Describe how the volume was determined:
Weather conditions during SSO event. Cloudy
® YesINo❑ Unknown
Longitude(degrees/minute/second)•
-02-2012 Time• 10:30 pm
Incident End Dt 0�
(mm-dd-yyyy)
hh:mm AM/PM
Estimated Duration (Round to nearest hour):
(5) gallon bucket test. Estimated bucket filled in 1.5 minutes x180 minutes
Did SSO reach surface waters?
Surface water name: N/A
Did the SSO result in a fish kill?
SPECIFIC cause(s) of the SSO:
❑ Severe Natural Condition
❑ Inflow and Infiltration
❑ Vandalism
Immediate 24-hour verbal notification reported to:
❑✓ DWQ ❑ Emergency Mgmt.
❑ Yes ❑✓ No ❑ Unknown
Volume reaching surface waters (gallons): N/A
If Yes, what is the estimated number of fish killed?
Grease
Pump Station Equipment Failure
Debris in line
Allen Johnson
❑✓ Roots
❑ Power outage
❑ Other (Please explain in Part II)
Date (mm-dd-yyyy): 08-03-2012
Time (hh:mm AM/PM): 4:55 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 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form
October 9, 2003
Page 1

Grease (Documentation such as cleaning, inspections, enforcement actions, past overflow reports,
educational material and distribution date, etc. should be available upon request.)
When was the last time this specific line (or wet well) was cleaned? 20
Do you have an enforceable grease ordinance that requires new or retrofit of grease traps/interceptors? ,YeE No ❑ NA❑ NE
Have there been recent inspections and/or enforcement actions taken on nearby restaurants or other ❑ YeN
nonresidential grease contributors?
Explain.
Have there been other SSOs or blockages in this area that were also caused by grease?
When?
° If yes, describe them:
AD NE
oDNAONE
Have cleaning and inspections ever been increased at this location?
Explain.
Have educational materials about grease been distributed in the past?
When?
and to whom?
o0NADNE
YeU Nol iNAQNE
2_c l)
Explain? / 1 i
Di S7�rI b o Ted' aui vt. AA%+vq ey Cie T/L fi // LJUS70/-ilPcS
•
If the SSO occurred at a pump station, yW�efi was the well arfd pumps last checked for grease
accumulation? �/
Were the floats clean? ❑ Ye0 N
Comments:
CS-SSO Form Page 4

Roots
Do you have an active root control program on the line / area in question? ❑ Ye, No ❑ NA❑ NE
Describe
Have cleaning and inspections ever been increased at this location because of roots?
Explain:
o❑NA❑NE
What corrective actions have been accomplished at the SSO location (and surrounding system if
associated with the SSO)?
What corrective actions are planned at the SSO location to reduce root intrusion?tr�,�/ ,(
1n/� Prt L�.lCc�/i?P/4 C7 a vY,;/ve i— %dvy t�f %� GrPO SOY%�/!2 /7CJ/UN/S /K9t/ c
Has tt a line been smoke tested or videoed within the past year? < 0 YeErlo 0 NA❑ NE
If Yes, when?
Comments:
CS-SSO Form Page 5

System Visitation
ORC
Backup
Name:
Cert#
Date visited:
Time visited:
How was the SSO remediated (i.e. Stopped and cleaned up)?
�,,frk-c7P �/ 7/ / flirr '/ YJ/ , .5e /e�r av gxx,-/�.> 4e0 LiAd
S,oTe4o 25 /6s ofi- /,nee ai-ours/ 744 , ,vJo/e
As a representative for the responsible party, I certify that the information contained in this report is true and accurate to
the best of my knowledge.
Person submitting claim: Ifiri7 4tiri
Signature:
D/
Telephone Number: 764/- 376 - ? y /
Title:
Date: 8/S
%Z
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five days of first
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of this
form is completed, if used).
CS-SSO Form Page 15

1;zl
� i
Collection System. SSO 24-Hour Notification
Collection System: Number and Name WQCS# ob233
Incident Number from BIMS
Incident Reviewed (Date): .
Incident Action Taken: BPJ • •
NOV-2010-DV 0
N°'3
Spill Date • 1�3� Time • elb/ prri
S.IC'
Reported Date / • •. Time am/.
Reported To SWP Staff o EM fart •
Reported By—�}f(�( 1. . • �,
Address of Spill
• :County
Cause of Spill ( _ /i
Total Estimated Gallons
Stream
• City.
Est...Gal to Stream
Fish Kill: Yes No Number
Species.
Non. Required Informationand other comments relating to SSO incident:
Response time
• minutes . Zone Map Quad. •
i

Permit# ..
WQCS00253
WQCS00196
WQCS00233
WQCS00001
WQCS00016
WQCS00046
Owner and Facility Name
Bradfield Farms Waler Company CS
Carolina Wafer Service Cabarrus Woods CS
Carolina WalerService HembyAcres CS
Charlotte -Mecklenburg CS
City of Albemarle CS
City of Belmont CS •
WQCS00107 • City of Bessemer City CS
WQCS00089 Cityof Cherryville CS• •
WQCS00221
WQCS00326
VS/QCS00088
WQCS00017
WQCS00020
WQCSOD327
WQCS0D036
WQCS00040
. WQCS00164
WQCS00026
WQCS00059
WQCS00044
WQCS00019
WQCS00037
WQCS0o030
WQCS00149
City of Claremont CS
City of Concord CS
City of Conover CS
City of Gastonia CS
City of Hickory CS '
City of Kannapolis CS
City •of Kings Mountain CS
City of Lincolnlon CS •
City of Lowell CS •
City of Monroe CS •
'City of Mount Holly• CS
:City of Newton CS .
City. of Salisbury CS
City of Shelby CS •
City of Statesville CS
East Lincoln CS
Permit #
WQCS00171
WQCS00322
WQCS00222
. WQCS00341
Owner and Facility Name •
Greater Badin CS
Aqua Country Woods East CS
Town_of Boiling Springs CS
Town of China Grove CS
WQCS00231 'Town.of Cleveland CS
• WQCS00058 Town of Cramerton CS
• WQCS0016S Town of Dallas CS
• WQCS00342 Town of E.-Spencer CS
• . WQCS0032B Town of Harrisburg CS
*WQCS00343 Town of Landis CS
WQCS00310 •Town of Lorsgview CS
. WQCS00120 Town of'Maiden CS
WQCS00344. Town of Marshville•CS
• WQCS00043 Town of Mooresville CS
1NQCS00125 Town of Mt Pleasant CS,
• • WQCS00153 Town of Norwood CS
WQCS00190 Town of Qakboro CS • .
WQCS00325 Town of Stanfield CS
• WQCS00180 Town of Stanley CS
• • W.QCS00135 Town of Taylorsville CS
• WQCS0025B Town of Trou{man CS
WQCS00345 Town of Wingate CS
'WQCS00054 Union County CS
WOCS00009 . WSA Cabarrus Co. CS •
•Deemed Permitted.
Permit# "Owner and Facility Name •
WQCS00130 Brooks Food Group -Brooks Food Group
WQCS00114 Charlotte Mecklenburg Schools MiscLalerals
WQCSD0057 City of High Shoals CS.. .
WQCSD0117 Duke Energy Marshall Steam Station
WQCSD0257 Fallslon • •
WQCSD0116 Goose Creek Utilities Fairfield Plantation WWTP
WQCSD01O1 Harborside Dey LLC-Midtown T CS
WQCSD0095 Kennerly Dev. Group LLC-Boardwalk Villas CS
•
WQCSD0098 Kennerly Dev, Group LLC-Kings Point CS
WQCSD01D5 Kennerly Dev. Group LLC-Moon Bay Condos CS
WQCSD0107 Kennerly Dev. Group LLC-Schooner Bay CS
WQCSD0099 Kennerly Dev. Group LLC-Spinnaker Point CS
WQCSD0258 Kingstown
WQCSD0112 Lake Norman -South Point CS..
WQCSDD104 Lake Norman -Villas S Harbour CS"
WQCSDO102 Lake Norman -Vineyard Pt Resort CS
Permit# Owner and Facility Name
WQCSD0064 • Lincoln County CS .
WOCSD0097 Martin'Dev Gp-N Point & Portside CS
' • WQCSD0120 Martin Marietta Mallard Creek '
WQCSD0019 Town of Richfield CS
WQCSDO024 Town of Grover CS
WQCSDOD38 Town of McAdenville CS
WQCSD0002 • Town of Ranlo CS
WQCSD0049 Town of Spencer Mountain CS.
WQCSD0252 All spills which do not have a permit
number assigned

07/08/2010 02:44 7045982872
CASARRUS WOODS
PAGE 01/07
[iiJ1cAaARus
,3 J ��i. S � L I _ i' ! .. w AT E 'S3. u' N .) ix. 'gf ��{r 'lJ. 5$�+ NC,
y'rODS L 7 S
10421 STARWOOD DRIVE
. IHARRISBURG,N.C.
!FAX (70 )- 8- 72
PHONE # [phone]
FAX COVER HE T
To:
Fax N er:
Pb,00e Ntunber: - _ Re_
rr
FYI Review CaI Per Your Reque8
•
Thia message is for the named s& omy ,T rimy conic€iv. 5easitive, 1?vaie or protectrecl informcvim, !'�1M;
confidentiality pTivilege is zsagued or lost by any miatrsa-.,s zissi,In, are not the inte4decl racip 4t., plecze
notify the sans immediately tely at the telephod-s4 rztm er I;stj above.is ittg.o;-egy.zs, ied thatyo inuns,diateiy
mail the trartsmiselot. to the ccd rgsg to'kraa_ 2oZ4 zrz.U5t ?W , diras.°tdy or. r ,�etwt, use, disedo$e, dietribute, print,
o - copy parr of this Yrees4cw if yare. ;mat the ferd 3 rrcipina.
pl,S�C�iS'Sv-cs(
•

07/08/2010 02:44 7045982872 CABARRUS WOODS
PAGE 02/07
Manhole#
Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
V 1 /2009 PART
This form shall be submitted.to the appropriate DWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Penne Number: '�
0 (vvr c&tt; if aceve, otherwise use WOCSD#)
Facility: 5 Incident #
owner, 77,a."0 i iv-Ift !ii/R'J / f ' c Raglan:
City: {,9N %Ixri County:
Source Of SSC, (check applicaele) :
Pump Station / Lift Station
SPECIFIC location of the SSO (be consistent in descriop from p94 reports or documentation - Le. P p floe 6,
Manhole at Westell & Bragg Street, etc,) : Aftt ✓J►o/te. �nr , 1///Fp,�+ e !�
Sanitary Sewer
0
• Latitude (degrees/minute/second): Longitude(degreeslmineteJsecond)
incident Started Dt: a 30 -a.o/ p . Tme: 1/' a a Syr± r
(mmUdd-yyyy) hh:mm AMIPM
900
Estimated volume of the SSO:
Describe how the volume was determined:
Weather conditions during SSO event
Did S SO reach surface waters? Q Yes
Surface water name:
gallons
V1rc J/
from-d& yYY)
Incident End De , or24/O Time. 12 3c eerie
hh:mm AMNM
Estimated Duration (Round to nearest hour):
f No❑ Unknown
Did the SSO result in a fish kill? { Yes f r`r00 Unknown
SPECIFIC ca, e(s) of the SSO:
Severe Natural Gonditiort
• inflow and Infiltration
❑. Vandalism
• Pipe Failure (Break)
24-hour verbal notification
cation (name of person contacted)
>,.__�! DWQ LV i=mergency Mgint.
0
0
0
Volta -Tie reaching surface waters (gallons):
If Yes, what is the estimated number of fish killed?
Grease
Pump Station Equipment Failure
Debris in Iirre
0 Roots
O Power outage
Q Other (Please explain la Part ID)
,5-4 ale-('s
Date (mm-dd-yyyy)' 7 /'/c
Tlnie (hh:mrn ANtiPl17)' t /Qrin•t
If an SSO la ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G,S, 143-215.1C(b), the responsible party of a discharge of 1,000 gallons or more of untreated wastewater to surface
waters shall issue a press release within 48-hours of first knowledge to all print and eleetrnnio news media providing general
coverage in the countycountywhWtrimitscharge occurred_ When 15,000 gallons or more of untreated wastewater enters surface
waters, s public notice shall be published within le days end proof of publication shall be provided to the Division within 30 clays,
Refer to the reti+enced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSQs that are required to be reported to Division unless it
Is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Perm)ttee
and/or owner, and the discharge could not Crave been prevented by the exercise of reasonable control.
Part 11 must be completed to provide a justihoatiion claim for either of the above situations_ This information will be the basis
for the determination of any enforcement action. Therefoia, itis important to be as complete as possible.
WHETHER OR NOT PART 11 IS COMPLETED, A SIGNATURE 1S REQUIRED AT THE END OF THIS FORM,
CS-,SSO Form
Page 1

07/08/2010 02:44 7045982872
CABARRUS WOODS
PAGE 03/07
Severe Natural Condition (hurricane, tornado, etc.)
Describe the "severe natural condition" in detail?
r
cN(/T'€'s
How much advance warning did you have and what actions were taken in preparation for the event?
YEA
Comments:
i
OA/ Pr
CS-sSO Faroe
5' e.4. 7at
Page

07/08/2010 02:44 7045982872
CABARRUS WOODS PAGE 04/07
System Visitation
ORO
Backup
Name:
Cert#
Date visited:
Time visited:
How was the SSO ramedisted (i.e. Stopped and cleaned up)?
ci
.tee'
tyres
Yes
As a representative for the responsible party, i certify that the information contained in this report is true and accurate to
the best of my knowledge.
Person submitting claim:
J,ct rr y ff rt/ y
Signature:
Title:
Date:
7 /r/ia
L, 6 / .,fi r
Telephone Number: `-to-q- 3 644 - r, f yi
Any additional information desired to be submitted should be sent to the approprigte Ravi&ion Region& Office within five days•of first
knowledge of the 55O with reference to the incident number (the incident number is only generated when electronic entry of this
form is completed, if used).
CS-SSO Form
Page 15

North Carolina Emergency Management - EM43 Reporting Page 1 of 3
North Carolina Emergency Management - EM43 Reporting
Print
Return To List
EM Level:
4
Taken by:
J Peters
Reported by:
Larry Henry
County:
Union
Street Address:
Mill Grove Rd Manhole #
Type: Wastewater
Animal Disease Event Type:
Complaint Event Type:
FNF Event Type:
HazMat Event Type:
Homeland Security Event:
Other Event Type:
Transportation Event Type:
Weather Event Type:
State Resource Request
NCEM Edited:
Yes
Date/Time Reported:
07/01/2010 17:11:51
Agency:
Carolina Water Service
City:
Indian Trail
EVENT TYPE
Bomb Threat Event Type:
Fire Event Type:
FNF Class:
HazMat Class:
Non-FNF Event:
SAR Type:
Wastewater Event Type:
Sewage
Weather Event Name:
Include in Report:
Yes
Date/Time Occurred:
06/30/2010 14:30:51
Phone:
704-361-1641
Area:
13
Zip Code:
HazMat Mode:
Non-FNF Event Type:
WMD Event Type:
Event Description:
Local utilities advised that an unknown amount of sewage spilled due to heavy rain. Spill started at
1430 hrs and ended at 1530 hrs. No water source was affected. Clean up was done by applying lime
to the area.
Filename:
Deaths:
0
Responsible Party:
Point of Contact:
Latitude:
00.000000
RRT Request:
Injuries:
0
RRT Approved:
Evacuation:
0
Responsible Party Phone:
Point of Contact Phone:
Longitude:
00.000000
RRT Team
Radius:
0
RRT Mission
https://www.ncsparta.net/e.oc7/boards/board. aspx?tableid=275 &viewid=1011 &label=EM-4... 7/2/2010

Address of Spill
County
Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS#
Incident Number from BIMS (-)Zt 1
Incident Reviewed (Date):
Incident Action Taken:
BPJ
NOV-2009-DV
Spill Date
((3 bs Time 1--(':3am/fa
Reported Date !I (1`t !tie\ Time ( am/ 0,
Reported To SWP Staff or MMStaff C_Sr,r� S Tr
Reported By C2-3SY`�-+ L''— Phone
. - 1
W^` City CPO
CO
Cause of Spill (- es
Total Estimated Gallons 7 5 Est. Gal to Stream
Stream 5(11/4i. —�� Fish Kill: Yes No Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad

r
Permit # Owner and Facility Name
WOCS00253 Bradfield Farms Water Company CS
. WQCS00196
WQCS00233
WQCS00001
WQCS00016
WQCS00046
WQCS00107'
Carolina Water Service Cabarrus Woods CS
Carolina Water Service Hemby Acres CS
Charlotte -Mecklenburg CS
City of Albemarle CS
City of Belmont CS
City of Bessemer City CS
WQCS00089 City of Cherr}ville CS
WQCS00221 City of. _Clare moot CS
WQCS00326
WQCS00088
WQCS00017
WQCS00020
WQCS00327
WQCS00036.
WQCS00040
WQCS00164
WQCS00026
WQCS00059
WQCS00044
WQCS00019
WQCS00037
WQCS00030
WQCS00149
City of Concord CS
City of Conover CS
City of Gastonia CS .
City of Hickory CS..
City of Kannapolis CS
City of Kings Mountain CS
City of Lincolnton CS
City of Lowell CS
City of Monroe CS
City of Mount Holly CS
City of Newton CS
City of Salisbury CS
City of Shelby CS
City of Statesville CS
East Lincoln CS'
Permit #
WQCS00171
WQCS00322
W0CS00222
WQCS00341
WQCS00231
WQCS00058
WQCS00165
WQCS00342
Owner and Facility Name
Greater Badin CS
Aqua Country Woods East CS
Town of Boiling Springs CS
Town of China Grove CS
Town of Cleveland CS
Town of Cramerton CS
Town of Dallas CS
Town of E. Spencer CS
. WQCS00328—Town of Harrisburg CS-
WQCS00343
WQCS00310
WQCS00120
WQCS00344
WQCS00043
WQCS00125
WQCS00153
WQCS00190
WQCS00325
WQCS00180
WQCS00135
WQCS00258
WQCS00345
WQCS00054
WQCS00009
Town of Landis CS
Town of Longview CS
Town of Maiden CS •
Town of Marshville CS
Town of Mooresville CS
Town of Mt Pleasant CS
Town of Norwood CS
Town of Oakboro CS
Town of Stanfield CS
Town of Stanley CS
Town of Taylorsville CS
Town of Troutman CS
Town of Wingate CS
Union County CS
WSA Cabarrus Co. CS
Deemed Permitted
Permit #
WQCSD0130
WQCSD0114
WQCS D0057
WQCSD0117
WQCSD0257
WOCSD0116
WQCSD0101
WQCS D0095
WQCS D0098
WQCSD0105
WOCSD0107
WQCS D0099
WQCSD0258
WQCSD0112
VVOCS D0104
WQCS D0102
Owner and Facility Name .
Brooks Food Group -Brooks Food Group
Charlotte Mecklenburg Schools - Misc Laterals
City of High Shoals CS .
Duke Energy Marshall Steam Station
Fallstor
Goose Creek Utilities Fairfield Plantation WWTP
Harborside Dev LLC-Midtown T CS
Kennerly Dev, Group LLC-Boardwalk Villas CS
Kennerly Dev. Group LLC-Kings Point CS
Kennerly Dev. Group LLC-Moon Bay Condos CS
Kennerly Dev. Group LLC-Schooner Bay CS
Kennerly Dev. Group LLC-Spinnaker Point CS
Kingstown
Lake Norman -South Point CS
Lake Norman -Villas S Harbour CS
Lake Norman -Vineyard PI Resort CS
Permit f
WQCSD0064
. WQCSD0097
WQCSD0120
WQCSD0019
WQCSD0024
WQCSD0038
WQCSD0002
•' WQCSD0049
Owner and Facility Name
Lincoln County CS
Martin Dev Gp-N Point & Portside CS
Martin Marietta Mallard Creek
Town of Richfield CS
Town of Grover CS
Town of McAdenville CS
Town of Ranlo CS
Town of Spencer Mountain CS
WQCSD0252 All spills.which do not have a permit
number assigned

Form CS-SSO
NOV 2 0 2009 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). -
Permif Number : A3e.0(U3SIPLj 1 (WQCS# if active, otherwise uae WQCSD#)
Facility. I -Peth AMC-5 Incident #
Owner: UT/ La-he,-5 nt4.,,, 9-4,2,-/A1,19-- f.th9-7e-R.-t1l2E ©T / Region:.
City ,.LSD/A-Al %I /L- . 'IOC- County.
Source of SSO (check applicable) : ' psi Sanitary Sewer 0 •
Pump Station / Lift Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation - i.e. Pump Station 6,
Manhole at Westhll & Bragg Street, etc.) : M/'}U l-M) t el/Li 66-.4. ° . )�.,. ,i )er}*tt ,g6/tc�,-1 iiii -
(A)"i p A)
Manhole#
Latitude (degrees/minute/second): Longitude(degreeslminute/second)
Volume reaching surface waters (gallons):
Surface water name: /U0.uE — SflMfr1 u_9i9'%FR, ji ref./ •
Did the SSO result in a fish kill? 0 Yes No❑ Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
0 Severe Natural Condition ,g Grease Roots
0 Inflow and Infiltration 0 Pump Station Equipment Failure 0 Power outage
❑ Vandalism ❑ Debris in line 0 Other (Please explain in Part II)
❑ Pipe Failure (Break) ),�/
24-hour verbal notification (name of person contacted) C d� -) /5
Er-LIWQ ❑ Emergency Mgmt.
Incident Started Dt: 1i ' 13 -2a9 I Time: 04 3D PM Incident End Dt: ) / - /3 - 69 Time. 127 .'1� P'M
(mm-dd-yyyy) hh:mm AM/PM (mm-dd-yyyy) hh:mm AM/PM
Estimated volume of the SSO. • .6-Se7 gallons • Estimated Duration (Round to nearest hour). 3
Describe how thevolume was determined: Iii51).0 L_ 013.5-11t4 MJ ,7 F F'&91-1 X 77 E
Weather conditions during SSO event: &L Er�R
Did SSO reach surface waters? r4 Yes 0 No❑ Unknown
r,
31�a
Date (mm-dd-yyyy)"
Time (hh:mm AM/PM).
If an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 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 10 days and proof of publication shall be provided to the Division within 30 days.
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of the Permittee
and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations, This information will be the basis
for the determination of any enforcement action. Therefore, it is important to be as complete as possible.
WHETHER OR NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
CS-SSO Form
) 9,/06 Page 1

Grease (Documentation such as cleaning, inspections, enforcern ent actions, past overflow reports,
educational material and disfribution date, etc. should be available upo n 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.
Have there been other SSOs or blockages in this area that were also caused by grease?
When?
If yes, describe them:
El Yea No❑NA❑NE
❑ Yea NoM NA❑ NE
❑ Yea No ❑ NA ❑ NE
Have cleaning and inspections ever been increased at this location?
Explain.
❑Yea No❑NA❑NE
Have educational materials about grease been distributed in the past?
When?
and to whom?
Explain?
YeLJ No ❑ NAD NE
if the SSO occurred at a pump station, when was the wet well and pumps last checked for grease
accumulation?
Were the floats clean? 0 YeC No pQ NA❑ NE
Comments:
CS-SSO Form Page 4

System Visitation
ORC
Backup
Name:
Cert#
Al -Q„U, LV Gt-t r
Yes
Yes
Date visited: 11 I (? 10
Mine visited: 1
How was the SSO remediated (i.e. Stopped and cleaned up)? 12iL) 7nnL%ID P,,J,z �
were--R. --s(T//)- 60,0) P p)E uT %Z e 119,' 1
As a representative for the responsible party, t certify that the information contained in this report is true arid accurate to
the best of my knowledge.
Person submitting claim:
Date:
Signature: iC !GIC_ Title: . d)",007A
Telephone Number:
.53?5-- 795'
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five days of first
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of this
form is completed, if used). �L / / �� cL e fr"� q� r/ v� J e
P ) Cf%W7'r2v7-` r rr��l C� l�oai a- �N S i �' l h' II�� (�-(-�
(6,5 /r/ � rfi.✓I. 1 �1.t- G,.rC�� �„"k�
a--d / J 4, Sd4vi /'' FF� th•Cr.a.� ��-c r 9
I, r 1—Kb
�'' ) iUd71 ?ird f G✓��• �G' Adti" !,•^f ,v p- .7� �t ,1 �,� ( (� I I
C if G IL•6 el 4 1 K L ie V s tL I1 Urv:I ` � R"dl �t�l d fi f M (� Vo / �'N' to t GI� w'TT' - +"-A V�cl
emu"` I✓1 k•
CS-SSO Form
Page 15

Collection System SSO 24-Hour Notification
Collection System: Number and Name WQCS# 06,:23.3
Incident Number from BIMS 0 l.(4 s'
Incident Reviewed (Date):
Incident Action Taken: BPJ
NOV-2007-DV
Sv�'
Pill Date �� Time S,(s am/ e141
Reported Date 06761M Time 7 s( am/
Reported To SWP Staff or EM Staff
Reported By l-G;,Y r vI Phone - 5-7 02 0
Address of Spill (O (3) /1 i! I( rbvJ
County ��1i1,`1�City
n
Cause of Spill Qinit>6 r cfv''
Total Estimated Gallons $(SD Est. Gal to Stream
Stream
umber Species
Non Required Information and other comments relating to SSO incident:
Response time minutes Zone Map Quad
(od.ate600,
;;-L, 6.0_41_(s0

Coliection System SSO 24-Hour Notification
Collection System: Number a
Incident Number from BIMS
Incident Reviewed (Date):
Incident Action Taken:
nd Name WQCS#
20150
BPJ
NOV-2015-DV
DV-2015-
0 CI El El 0 0 E3 0 13 E3 El El El 0 El CI 111 CI 0 CI CI El CI 13 0 0 CI 0 13 13 0 El CI CI El El 13 CI CI LI II 0 El I3 0 13 0 0 CI 0 13 El El E3 0 13 13 13 DI CI 0 El 13 111 13 CI A
Spill Date (I i 51/3— Tirne G k 0
am/ CU e r fol
Reported Date t( ( (0 ((c Time q 175-
et.54 5,5r1
Reported To SWP Staff or EM Staff • A
Reported By- (1114114- I-1A*7N- -Phone
Address of SpiII idleithlei CMilinid_Ve-t4Alar:)jkal CA 12-01./iN 0 &Of-792- 8A1 a --
County dift:t.CA,-, City
-----
___Caute-of Spill CH 6 (Z- 07,C( af ,boAks NeAr siadwit
c
--rotal-Estimated Gallons ' a -o-Stream -'-"fae'/
•Opm
Stream FD&Coroc) C-ur,
Fish Kill: Yes Number Species
Non Required Information and other comments relating to SSO incident:
Response time minutes
3 0
Zone Map Quad
5 c_ 5fr

Permit#
WQCSD0130
WQCSD0114
WQCSD0057
WQCSD0117
WQCSD0257
WQCSD0116
WQCSD0101
WQCSD0095
WQCSD0098
WQCSD0105
WQCSD0107.
WQCSD0099
WQCSD025B
WQCSDD112
WQCSD01D4
WQCSD0102
Permit #
WQCS00253
WQCS00196
WQCS00233
WQCS00001
WQCS00016
WQCS00046
WQCS00107
WQCS00089
WQCS00221
WQCS00326
WQCS0008B
WQCS00017
WQCS00020
WQCS00327
WQCS00036
WQCS00040
WQCS00164
WQCS00026 •
WQCS00059
WQCS00044
WQCS00019
WQCS00D37
WQCS00030
Owner and Facility Name
Bradfield Farms Water Company CS
Carolina Water Service Cabarrus Woods CS
Carolina Water -Service HembyAcres CS
Charlotte -Mecklenburg CS
City of Albemarle CS
City of Belmont CS
City of Bessemer City CS
City of Cherryville CS -
City of Claremont CS
City of Concord CS
City of Conover CS
City of Gastonia CS
City of Hickory CS •
City of Kannapolis CS
City of Kings Mountain CS
City of Lincolnton CS
City of Lowell CS
City of Monroe CS
City of Mount Holly CS :
City of Newton CS
City of SalisburyCS
City of Shelby CS .
City of Statesville CS
' Permit#
'WQCS00171
WQCS00322
WQCS00222
WQCS00341
WQCS00231
WQCS00058
WQCS00165
WQCS00342
WQCS00328
WQCS00343
WQCS00310
WQCS00120
WQCS00344
WQCS00043
WQCS00125
WQCS00153
WQCS00190
WQCS00325
WQCS00180
WQCS00135
WQCS00258
WQCS00345
WQCS00054
•
Owner and Facility Name
Greater Badin CS •
Aqua Country Woods East CS
Town of Boiling Springs CS
Town. of China Grove C5
Town of Cleveland CS
Town of Cramerton CS
Town of Dallas CS
Town of E. Spencer CS.
Town of Harrisburg CS
Town of Landis CS
Town of Longview CS
Town of Maiden CS
Town of Marshville•CS
Town of Mooresville. CS
Town of Mt Pleasant CS.
Town of Norwood CS
Town of Oakboro CS •
Town of Stanfield CS
Town of Stanley CS •
Town of. TTaylorsville CS
Town of Troutman CS
Town of Wingate CS
Union County CS
•
WQCS00149
East Lincoln CS
WQCS00009 WSA Cabarrus Co. CS . .
Deemed Permitted
Owner and Facility Name
Brooks Food Group -Brooks Food Group
Charlotte Mecklenburg Schools - Misc Laterals
City of High Shoals CS •
Duke Energy Marshall Steam Station
Fallston
Gopse Creek Utilities Fairfield Plantation WWTP
Harborside Dev LLC-Midtown T CS
Kennerly Dev. .Group LLC-Boardwalk Villas CS
Kennedy Dev. Group LLC-Kings Point CS
Kennerly Dev. Group LLC-Moon Bay Condos CS
Kennerly Dev. Group LLC-Schooner Bay CS
Kennerly Dev. Group LLC-Spinnaker Point CS
Kingstown .. .
Lake Norman -South Point CS
Lake Norman -Villas S Harbour CS
Lake Norman -Vineyard Pt Resort CS
Permit# Owner and Facility Name
WQCSD0064 Lincoln County CS
WQCSD0097 Martin Dev Gp-N Point & Portside CS
WQCSD0120 Martin Marietta Mallard Creek
WQCSD0019 Town of Richfield CS
WQCSD0024 Town of Grover CS -
WQCSD0038 Town of McAdenville CS
WQCSD0002 Town of Ranlo CS .
WQCSD0049 Town of Spencer Mountain CS.
WQCSD0252 All spills which do not have a permit
number assigned

'Division of WaterResonirces
ateofN�rthrolifla
_
.1Repartinent of Environment and,Natatat Resources
Division ofWatet_Wsoproes
colledtionSystem Sanitar y Sewer Overflowkeportiiik FOrin
Forth CS-SSO
:PART f the
Thts'fehriShall be submitted to the appropriate OVVR-Regional Cade within live business days of the first knowledge
Sanitary sewer overflow. 0$0),
- "
Permit Nurnber: WQ0$00233: (WQQ$0 ifactivei 011.**010: wpcspto
1riCidaritt:#1 OWner: Carolina Water SerVices,:lnO..:OfNc
RegioriMbqrSyllie P1/81R1 City Indian Trail County Union
Source Of SSO (check applicable): Sanitary Sewer 0 Pump Station -Station
SPECIFIC location ,of the 880:'(be Consistent in description frOM past reports or doctirrientatiorr,je;Ptirrip'
Stati�n 6,:Marihole at WeStallAlitogg Street, etc): Manhole near iiiterseCtiori of Ldlewild Rd &MiI1 ove Rd -
Manhole 4:54
LatitUde-(degreeStrnintiteliedendy, liingitude(degrees/mintite/Second)
InCidentiStartedOt:',1:1;LY-15 Time 15,40 IncidentEnd Dt 18i10;
.(hh:mrri) -AM/PM(rnin-dd-yyyy) (tihmirri) AM/PM
Eatirnatedvolumer of theSSCi'., -90,04allons,1 Estimated Duration (roundio nearest hour): la hitKir(s),
Describe, how..the'volume was determined ;:- as wcould not-do,a bucket tosf,becanse:,,OftitO,Iiigtitta#10 road and
the
amount .otrain and raiana off on road. 'DO.OadWapiwielly :flooded.
Weather.conditions during :ifie.,:$80,0!erit:: Raiti
Did the $tO-reaCh surface waterS7.1 tz] Yes., 4i1 El Unknown
Volurneleaciiing.surfacewatei* QOUbtisI $4,:ijap,6 Water -name: Fork Crooked:Creek
Did the §:b=result in afishkilt? DYes Z Na 0 tinknowm
lf-tes; whatia the eitirriated number of fish N/A:
SPECIFIC c.atise(s).of the SSO
0.$evere,Na1Pral,b9ricliiiqns ORbOts-
t] 'Grease F14 Inflow & infilt4tiort
OPuniri Stationtotiipmerit Failure D Power Outage ElVandellain El Denriain line OPIpe Failure (Break)
• D'Other,(01pape expleirrin Part*
24-hour verbal notification (name of person contacted) Andrew Pitner
DWR CIEIneren4 Management bate (rnm-ddinfy): 11-40-15, Time'. (hh:rnirfAlVI/PM)t-,0:23 ail?
Per G.S. 143-215.16(b),:the�wnerorbperatorOf any wastewatercollectionsySterri
I hthe event of a discharge Of 1,000jgallOns-or more, ofuntreated wastewater toithe surface watersOf the State; issue
a 'press release to alt print and electronic newsmedia that provide general coverage in the county where, the.
discharge occurred setting ,out the details Of thediaptiarge. The press release shall be issued within:, 24 hours : after
the ownei': operator has daterntinedthat•tnadigchargehas reached sarateWaters:pt tneState
In the event of a discharge of 15000 gallonsor more of 'untreated wastewater:- to the surface waters
of thepubhsh
4;rietiCe of the discharge in a newspaper ha4ing, general.circulation in the, county in which the discharge
occurs and in each ; courityrdowriOkoiti from the point of 'discharge that.is significantly affected by the discharge The.:
Regional Office Shall-getomiqo which counties are Significantly affected by the discharge*40hoi approve theform
and contentoithe,noticeandthe,neWSpaPers:in whiOhthe notice is published.
WHETHER.00:.,NOT PART 11 IS COIUIPLETED. A SIGNATURE IS REQUIRED SE PAGE 13
Form CS-SSO

Di on ol Waouces.
State:of NOrtli:Carrilina
Department of Environment and NatOirai Resources
Division., of Water 4eSources
Collection System Sanitary SeyieelayerfinW gook% Fovni,
.1741111$7.0
torm'eSSICI 'POge.2

for jOgficition ofan SSO; .you rnOrs(uoeTatit'll-p(fpftp:;6SO:witti additioRat d40C.ttilOhtt!911.40.-.
100.401*g.th IMIZst6ff wiltrevfewftie'fiistifid.Ofibil 010101:40-01.46!trnfrie ifenforcementaCti�fl.ig..00fdptia*.
;PART
,..AN$vvElk.THE-potiowNp QUESTIONS FOR EACH RELATED CAUSE CHECKED IN PART OF Ty0s,rdikM,AND
IK.LPP:E71-10A010170PRIAT5b010.0.MENTATI0M AS REqqikEtiitiktiEbikE0
COMPLETEONLY THOSE StCiTiN8'.PERTAININGTaTkE CALJSBOFTH 88C)ASCRECKPYIKPARt
(Inliie-gbeckt**.0 4elOW, 1,1A NcitApplicAble and NE„ --;N�t Evatua ).
&11,A13PPOP-OF:ItHi8.POMA:SHOULD:;13'PWBNiltfa jj TO THE PPROPAIATE:DWR REGIONAL OFFICE Cpciwos
.18.14AS113-14 SUBMUED PC17ibKiiLLY-ri-ifkb,ljOH, TH.OMLINF ri0001'100sYstEM
iPorni:OS.LS,810:

1
'Severe Natural Conditiona (hurricane, tornado,'etci)
Describe theusevere ri*Or-4.190001tfOrt" thdetaii: Read belOW1
How Much advance warning, didyou have:and what actiont Were tAkert in preparation for the event?'N0h0:W did not,
think 'Olaf wevitotild receive this rain nor did we think the creek would overflow;
Comments : tin.11,945. we received a eat from Union, County dispatch ihat there was a manhole hole that was allowing
water to come out of the_ vent holes on Mill Grove Road They said if was located in 'the road befOre'you get to Idlewild
Road. We received this call at 15:00. We •Eirriveti on -site at 15:10 and found water corning down the road from the Food
Lion parking lot going directlt tOwards'the'Manbble,‘ Tylaphole(#54): This is located in a high traffic area near the
intersection of fdlewild Road and Mill Grove Road Therewas water coming. out of the,thatihole hd at the tiine.lecause-of
the high traffic area there. was no way to it': and OOP the manhole down. There was no trash, rags or 001)xj0-:cOnking'.from
the manhole vents just wafer., This stopped at 1S:10 hours ons the 11-9=15. The water was still cOmingl.down from the
parking.lot after the.',SSO. so there was clean up The Fork Crooked Creek creek had also come out of its banks
and managed to contribute was no fiSh kills and no known public health risks . During our inspection of
the collection system the next day we found one manhole hole that may have casued a significant portion ofthis MT and
are:lodkinginto havinga contractor raise it ASAP We are also lookinginto, any Other posSibiltes that may have contributed
to this SS0.1Ve will datilititiele dd,What isuesseeary to eliminate SSO's.
ForM
ii!age4

Form C'§:48$0
Page 5

•Grease (Docurnefitation such as cleaning,insbectitin, eriforcementactions, past overflow repbrts, educational
material arid distribution date, etc. should be available Won reg_ueSt)
When -Wag the last timethiespecific wq.11) w0.§. 9!Pr190.
Do'you have an enferceable grease ordinante that requires new or retrofit of
,grease traps/interCeOtors? 0 Yes 0 No NA
Ell NE
Have there been recent inspection andtpr enforCement actions taken_on near-
t?s, reetaurants-or other nonresidential grease contributors?. 0 'Yes ONO ga 04 rINE.
Explain:
Havethere been othe(SSOs or blockageSjn this:areas that were also caused,
bygrease 0-Yes LINO NA 12, NE
When?
If yes, describe.thein:
Have Cleaning and inspections ever beensioneat this loc;atioh? El Yes :D No CI NA El NE'
PPlain.
Have educational Materiatabout:grease been distribded in the Oast? ,E1 yet 0 No ENA ID N
When
and tonwhom:
F.,xplaint
if the SSQocCurred et e-PtiMO's-tation,When was the Wet well and pumps tast checked,
for grease
Were. thefloats:cleen? El Yes1E1No. NA 0.NE.
-Comments:
Form CS -SO
1We'0'

koota-
Do you have an act* rOOViCoritt,o1 prcgram:on theline areain.ciue0b0 'ETY-es tqb NA [i]
NE
Describe:
Have Cleanitid..and'intpectibria Ott haenincreased at this location because
of roots?
What OOtradiVaaCtiona:tAvo been accomplished at.5the;SSO location (and.
.0.17.0),unitithg,aystatn:.if aaaociatect With the SSIO)li
Whafcorrective adtiona are planned atthiSSQ focation'toleduCe:rOat
‘Haatha linkheetWrhatteleate4 orvideoed Within the:Oak yeail
,if Yes ; when.f,
Comments;
Vorntg$0
Yea [1], No @NA D _NE
El NO.
Page 7

it -mow and infiltration
Are you tinder:an SOC (Special Orderby COnstrit) Or do you havea schedule 0Yes No DNA D NE
in any -permit that addresses VI?
Explainjf Yes:
VVhat coiTectiVe actions have heentaken tOreduce-or relatetrOverflOWs thisspiillocation
within the We have inspected.manhOles daring and after rain events to see where we might beliaving!afi
probleniWe will also conduct smoke tests wheneoaditie4s,pre beat •,to locate any other issues that contribute to
14as-therebeen any ilowatudieS ledeterrnine preblenrislh the
collection system at the 'SSOToCatien?
Yes,When Was:thestudycornpletecland What actioris did, it recommend?'
Has.the line. been SrnOketestectcr Videtied*thin the -past year? 0,Yes No DNA 0,,NE
D Yes el No DNA DNE
Yes,When anctvvhat actions' are necessary and theStatUSOf such -actions:
Are there l/I related projects in your Capital improvement Plan? Ei Yes No DNA Li NE,
tYeS, explain: Wehave monexset aside for inain replaceraentS: We have replaced numerigus sectihp&otinain„ rahabed
'Manholes oto, inthe.pastand we will continue to identify- tspAes and take corrective actions to illiininate
Have there been any grant or loan applicatiOnS fOr I/I reduction projects? 0 es D No NA
lf Yea, explain:
pciyou tuspectony'majorsourees of inflow or cross connections'
with stormseWere?
if yes, explain:, Yes we, did inthe past. but webelieve we have:corrected them, all over the year,
Have:oil:lines:contacting surface waters in the location and upstreath. El Yes 0 No CINA C] NE
been inspected recently'?
If Yes; explain We have inspected ime along the Fork Crooked this year and have raised manholes in an effort to keep
.creek water out as'AVellOS other storm water ditches where we have Manholes. ThiS'itteliides the ditches on theback side of
Beacon Hillsand Other, locations intletriby and Oak Grove:subdivision,
What Other Corrective actions are planned to prevent future WI related SSOs at this location? We are loriking at ateas. rnthe;
collection system' to smoke lest and camera so we can take proactive measure to illimmate I&I issues in the system We are
also loOking.at what we can do to eliminate surface runoff from infiltrating our manholes as well as when the Fork
Crooked Creek leaves:it's bankt.
derninerits:
a
Yes 0 NoDNA 0, NE
Form,S=gS0' -Pa4p'8

Pint) Station EquiptnerifFaiture (DOdurnentatibrCof testina records. eto:Shotildt&prOVided CIPOrtreOueSq.,.
_
.What:ktrid Ofr,nOtifi(atiOniaierrn syStems:arepresent?.:
Auto-Aialeritelemetry(Orie4kay torritrianiOation). 1:".1Yes,
Audible .El Y.P.P
VisUa 1,--T`4s
SCADA (tWo-utilaVoOrrimitniOotion). ;I:f:YeS•
Ertierterity'DOht64Signage::
Dther 0 Yes
f-Yes, explain:
DescribeDescrthe.theequipmeflt that-faile4::
What kind Of:.SitostiOnstri6ger an alarm coadition.a.t,:thiS station i e pump fiIure power failure high water, etO.)?
Were notificationialarirrsySterns operable?: II Yes CI No 1,11NA
In /16,,e4lairi:
If ppmofailed, when was the laSt maintenance ln0Or inspection performed':
WhafippOifically. Oeoicectimaintainedl
If eveNe'falleckwhen wasit lastexerOised?
Were allPumps set to alternate?
•
_lay, 0 No
NA, 0 NE,
Did any p_UrnP;shOlkabove-normatron hines.prfor toend duringthe SSD vent? , -0-Yes :ONO' NA.
Were adequate spare:patOn hand, tortix-the equipment
Was espareor pOrtabie parrip
itejleatPrOhleni, when were the floatS'iast tested? HOW?
If ati atite-dialel* orSCADA, wilen.wasthesystern lastteSte0?How?
PPIrrirn-Pnts:
Form CS.SSO
0 Ye
YesDNo 3
DNE
?age 9

Power outage (Documentation of testinP, records, tec., should be provided of alternative power source upon
rebuest.)
What is youraitemate power or -Pumping ource?
Djdit fOr1000Oroi)011Y7 El Yes 0 ,No NA El
Describe?
When wasithe.ajtOrnate:::powpf orpuniping:source,last tested 'under load?
If caused by:a weather event, hQW raUch,adv411'0e:•Warping did you have and what actions,iivere• taken :te prepate'forthe,
event?
'OmmentS"
'Form, C$7.SSO PagcIO

Vandalism
Provide polide
WesTie site; secured? i:i Yes NA D NE:
If:Yee,:ffel0
Have,there been previOue: Ofablenis*.it Varidelism:et the:S80,1ocetion?
if yo, oxplain:
Whatsecuntymeesiires: veOeeri', gut iriplace-to-prevent
'.occurrences iri the future?f•
dommenis:
Form CS`-SSO
ri.4 NA, Ei `
laYS ri
ra$e11

Debris in line (Rocks, sticks, rags and other iterns nOt allowed in the collection syStem, etc)
-Whaftypeiof debris hat beArtfOOnd'ifl the line?
i.Suspected cause Or soUrce of debris:
.Are manholes in the areaseatire and intect?, n Yes 0 No ZNA NE.
Wben CVaSthearealastchecked/c,lesined?
ilty,e, cleaning and inspections ever been increased at this lOCatinri
due tolprevious problems with.debris7
Are appropriate educationalMaterialS being'develOped and distributed:
to prevent future SiMilat occurrences?:
Comments:
Ei Yes 0 No NA El NE
Yea 11 NO NA 0 NE.
Perm CS-SSO, Pge 1-2

'3N El, VN
t].
:Cigg_,--5D 'taloa
4tiatu1U00
.,46g-g,041.4t;i-40004:01.0euasser,olublot-,4-4-0,w,
;01P,10.*--GA:AU
4weiqoid -04;.*:60i4010*'$66.4.00:03.:PkT waLudinbaanbetie,:a.i0AA
*-ectra0C1
tlppot)p4 lsnw, aqic1c.B Se Vqcipx.pogo0 pue:seinpd)

PiPeFailure (Bteak)
Pipe -size (inches)
Wttai is the Piltve rtliaterial
What is the approximate age of the line/ pipe (years old)
Is this a§rayity. 410 0 Yes El- No NA 0 NE
Is this a force main line?' 0 Yes: El No ,ZNA EINE
IS tile lirfea 'High' Priority' line?'
Yes El NQ
NA 0 NE
Last ihapeCtiOn date and finding
Ifa force Maikthen,
Was the break an the force Main,vertical? p Yes 12} No tp. NA 0' NE
Was the break on the force main horizontal' 0 Yes 0 No NA 0 NE
WaS,#ieleak atthejoiht OUP, geketfeil4re ? 0-Yes 0 No CI NA [1 NE:
Wes the leak at the loint due to split- bell? 0 Yes El No ZNA 0 NE
When was the last inspection or test the nearest air release valve to determine if operable?,
When was the last maintenance cif the air release permed?
ifgrayity sewer then;.
Does the line receive flow from A force main immediately upstream
:of thefailed sedticirt of pipe?
If yes, what measures are taken to control the hydrOgen-sulfide production?
NA DNE
When was the lihe,jest inspected �r Videoed?-
If:line collapsed; what is the condition of the iine, up and down stream of the:failure?
'What type of repair Ikea' made?
Ifterriperary',,Whan is the permanent repair planned?'
Havethere been other failures of this lirkeih the pastfive years? EI:Ydt. 0: No CONA
It$,Aheri describe
Forin.C8,-SSO, P.a4q 14

SV6tiem Visitation
pRc
Backup.
Nem* Mark- Riraver
.ertilication Number: '992155
Date 11,045'
Tinge 15:00'
Hp* iiyaS the BB0,rernediated `(i,16. Stopped and,cleanect,up)?.
No rags or debrielitmas,all ram water nothing te:clean-up.
Yes-,
0 Yes
•As a-representative:for-the responsible Partii, Idertifyilhat the inforrnatton containettin this,repoitis-true and ateurate tO the,
best of my knowledge,.
Persortsubmitting Ivtark.K.TWer
TelePh0,116-14unlbef: :704,31-0516
Date: 114245
. - -
ATV :adctition,al information desired 'to. be.submitted should Sent te the epprOpriete pivisiort Regional Office 'within fiire
business- days of first knOwledge of the BSc) With, reference to the - incident, number the incident number is onlygenerated,
„,
wheneleckeriip entiyof thisfirin is completed, if -used).
'IormCS SO P4ge14