WQ0013348_CS-SSO_20210827

Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
V 1/2009 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: WO op / 33 Yg (WQCS# if active, otherwise use WQCSD#)
Yh54-0
"Bel R.v,e,, As to
City: Oa.l iluvV
Source of SSO (check applicable) :
SPECIFIC
Facility:
Owner:
Incident #
Region:
County'
2021D1823
'ski„ Ea s •Fevet
Pavti 1 r c�
Sanitary Sewer ® Pump Station / Lift Station t`-v"TiG uy 4-Yee( 'd 4"lewC .0.0")
location of the SSO (be consisten in description from past.reports or documentation - i.e. Pump Station 6,
Manhole at Westal71- l & Bragg Street, etc.):
—D. t� ✓r Cy 3 CO I'ta.r.1t a Souk en, `y —limey R'-
Manhole#
' Latitude (degrees/minute/second): - Longitude(degrees/minute/second)'
Incident Started Dt: S-23- Z i Time: /2 tpai Incident End Dt: SC" 23"2 / Time: /2:3 J (PI
(mm-dd-yyyy) hh:mm AM/PM (mm-dd-yyyy) hh:mm AM/PM U
Estimated volume of the SSO• _ 3/ t700 gallons Estimated Duration (Round to nearest hour) 3v Yh.r
Describe how the volume was dete mined: /00 igel X 3 0 14•" -= '31D 0 0
Weather conditions during SSO even .StwfJify a" - R -0':R-,
Dld SSO reach surface waters? ►':� Yes El No__ Unknown Volume reaching surface waters (gallons):
Surface water name £.-44%. Wants 04 136-8/ R.t,a,
Did the SSO result in a fish kill? 0 Yes iLr No
SPECIFIC cause(s) of the SSO:
0 Severe Natural Condition
0 Inflow and Infiltration
0 Vandalism
Pipe Failure (Break)
24-hou verbal notification (name of person contacted)
DWQ E] Emergency Mgmt.
El
,qp 3/ 000
Unknown If Yes, what is the estimated number of fish killed?
0 Grease 0 Roots
® Pump Station Equipment Failure Power outage
Debris in line li Other (Please explain in Part II)
4'Viel_ (44
Date(mm-dd-yyyy).
Time (hh.mm AM/FM). /2' 34) POI
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 me 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, iris 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

Pipe Failure (Break)
Pipe size (inches)
What is the pipe material? UC.'r`., Xv0,, (frt
What is the approximate age of line/pipe? (years old)
Is this a gravity line?
Is this a force main line?
Is the line a "High Priority" line?
, Last Inspection date and findings
ZS yesys
oDNAP NE
9� No0NA®NE
f Yeli No ®NAD NE
If a force main then,
Was the break on the force main veritical?
YeN No 0 NA NE
Was the break on the force main horizantal? 0 Yea No 0 NA❑ NE
Was the leak at the joint due to gasket failure? DYe0 No ❑ NA❑ NE (Mtknoutt
Was the leak at the joint due to split bell? t_rYef No0NADNE LtYl Kna'Kvb
When was the last inspection or test of the nearest air -release valve to determine of operable?
When was the last maintenace of the air release performed?
If gravity sewer then,
Does the line receive flow from a force main immediately upstream of the failed section of pipe? 0 Yen No 9 NAIO NE
If yes, what measures are taken to control the hydrogen sulfide production?
When was the line last inspected orvldeoed?
CS-SSO Form Page 13

If line collapsed, what is the condition of the line up and down stream of the failure?
What type of repair was made?
Is the repair temporary' or permanent?
If temporary, when is the permanent repair planned?
evnian Qo-t
Have there been other failures of this line in the past five years?
If so, then describe
CS-SSO Form Page 14

System Visitation
ORC
Backup
Name:
Cert#
Date visited:
Time visited:
How was the SSD remediated (i.e. Stopped and cleaned up)?
g Yes
® Yes
Gy1 L Y^evN
,126019
$-23-2.1
all WG4t. 1,4s ilk Cited" k
As a representative for the responsible party, I certify that the information contained in this eport Is true and accurate to
the best of my knowledge.
Person submitting claim:
Signature:
Date: $ _ 27- Z I
Title: °KC
Telephone Number: 07 2 (7p - Ct6$"S
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five days of flrst
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
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