WQCS00137_Report_20210610

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Collection System SE nitary Sewer Overflow Reporting Form
'Division of Water Resources Form CS-SSO
PART I:
This form shall be submitted to the appropriate DWR Regional Office within five bt siness days of the first knowledge of the
sanitary sewer overflow(SSO).
Permit Number (WQCS#if active,otherwise use WQCSD#) h ,p
Of Sow rNpo�•1 aoo/oi3 ' Owner: �/7 of .Sow7'r/��`/
Facility:C/7y Incident#: Y
Region: City: Sot-,t He6 J2-N" County: ‘61"A/s"✓"A' RECEIVED
Source of SSO (check applicable):4 Sanitary Sewer ❑ Pump Station i Lift Station
SPECIFIC location of the SSO(be consistent in description from past reports or documentation-i.e. Pump UN 10 ZUZ1
Station 6, Manhole at Westall&Bragg Street,etc.):
Manhole#: C o td d g NCDE9IDWRINPDES
Latitude l re s/minute/second); Longitude(degrees/minute/second): L.,/ ©7r a/•
Incident Started Dt: / Time: Q. 3 a Incident End Dt: / Time://'44
(mm-dd-yyyy)c 6 -o`f"a O� / (hh:mm) I/PM (mm-dd-yyyy) d 6 ! (hh:mm)gA/PM
Estimated volume of the SSO:/q Stygallons Estimated Duration (round to nearest hour):/,, hour(s)
Describe how the volume was determined:,. ‘er✓1 ^-7,✓vt-55
Weather conditions during the SSO event: /kr"? R•oi�v C`•-" 'Z ',uclje5d
Did the SSO reach surface waters? ❑ Yes ,:i No ❑ Unknown
Volume reaching surface waters: gallons Surface water name:
Did the SSO result in a fish kill? ❑Yes rdlit No ❑ Unknown
If Yes,what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
❑Severe Natural Conditions ❑ Grease ❑Roots [Inflow&Infiltration
❑Pump Station Equipment Failure ❑ Power Outage ❑Vandalism ❑ Debris in line ❑Pipe Failure(Break)
❑Other(Please explain in Part II)
24-hour verbal notification (name of person contacted):
®DWR lAtEmergency Management Date(mm-dd ): Time: (hh:mm IIPM):
Per G.S. 143-215.1 C(b),the owner or operator of any wastewater collection system shall:
In the event of a discharge of 1,000 gallons or more of untreated wastewater to the surface waters of the State, issue
a press release to all print and electronic news media that provide general coverage in the county where the
discharge occurred setting out the details of the discharge. The press release shall be issued within 24 hours after
the owner or operator has determined that the discharge has reached surface waters of the State.
In the event of a discharge of 15,000 gallons or more of untreated wastewater .o the surface waters of the State,
publish a notice of the discharge in a newspaper having general circulation in the county in which the discharge
occurs and in each county downstream from the point of discharge that is significantly affected by the discharge. The
Regional Office shall determine which counties are significantly affected by the discharge and shall approve the form
and content of the notice and the newspapers in which the notice is published.
WHETHER OF NOT PART II IS COMPLETED,A SIGNATURE IS REQUIRED SEE PAGE 13
Form CS-SSO Page 1

In order to submit a claim for justification of an SSO,you must use Part II of form CS-SSO with additional documentation as
necessary. DWR staff will review the justification claim and determine if enforcement action is appropriate.
PART II:
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN PART I OF THIS FORM AND
INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTONS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN PART I
(In the check boxes below, NA= Not Applicable and NE=Not Evaluated)
A HARDCOPY OF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWR REGIONAL OFFICE UNLESS
IS HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Form CS-SSO Page 2

Severe Natural Conditions (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:
Form CS-SSO Page 3

Grease(Documentation such as cleaning, inspection,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?
Do you have an enforceable grease ordinance that requires new or retrofit of
grease traps/interceptors? ❑Yes ❑ No ❑ NA re NE
Have there been recent inspection and/or enforcement actions taken on near-
by restaurants or other nonresidential grease contributors? ❑ Yes ❑ No DNA KNE
Explain:
Have there been other SSOs or blockages in this areas that were also caused
by grease ❑ Yes ❑ No ❑NA M NE
When?
If yes,describe them:
Have cleaning and inspections ever been done at this location? ❑ Yes ❑ No ❑NA 2 NE
Explain.
Have educational material about grease been distributed in the past? ❑ Yes ❑ No ❑NA 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? ❑ Yes ❑ No ❑NA E
Comments:
Form CS-SSO Page 4

Roots
Do you have an active root control program on the line/area in question? ❑ Yes ❑ No ❑NA 71 NE
Describe:
Have cleaning and inspections ever been increased at this location because
of roots? ❑ Yes ❑ No ❑NA NE
Explain:
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? ❑ Yes ❑ No ❑NA NE
If Yes,when?
Comments:
Form CS-SSO Page 5

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Pump Station Equipment Failure(Documentation of testing records, etc should be provided upon request)
What kind of notification/alarm systems are present?
Auto-dialer/telemetry(one-way communication) ❑ Yes
Audible Yes
Visual Yes
SCADA(two-way communication) ❑ Yes
Emergency Contact Signage ❑ Yes
Other ❑ Yes
If Yes, explain:
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.)?
Were notification/alarm systems operable? ❑ Yes ❑ No DNA '® NE
In no,explain:
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? ❑ Yes ❑ No DNA NE
Did any pump show above normal run times prior to and during the SSO event? ❑ Yes ❑ No ❑NA 11 NE
Were adequate spare parts on hand to fix the equipment ❑ Yes ❑ No DNA [ ] NE
Was a spare or portable pump immediately available? ❑ Yes ❑ No DNA 411 NE
If a float problem,when were the floats last tested? How?
If an auto-dialer or SCADA,when was the system last tested? How?
Comments:
Form CS-SSO Page 7

Power outage (Documentation of testing, records, tec., should be provided of alternative power source upon
request.)
What is your alternate power or pumping source?
Did it function properly? ❑ Yes ❑ No ❑NA ciiiA NE
Describe?
When was the alternate power or pumping source last tested under load?
If caused by a weather event, how much advance warning did you have and what actions were taken to prepare for the
event?
Comments:
Form CS-SSO Page 8

Vandalism
Provide police report number:
Was the site secured? ❑ Yes ❑ No ❑NA zfr NE
If Yes, how?
Have there been previous problems with vandalism at the SSO location?
If Yes, explain:
What security measures have been put in place to prevent similar ❑ Yes ❑ No ❑NA NE
occurrences in the future?
Comments:
Form CS-SSO Page 9

Debris in line (Rocks, sticks, rags and other items not allowed in the collection system, etc.)
What type of debris has been found in the line?
Suspected cause or source of debris:
Are manholes in the area secure and intact? ❑ Yes ❑ No DNA 191-NE
When was the area last checked/cleaned?
Have cleaning and inspections ever been increased at this location ❑ Yes ❑ No DNA NE
due to previous problems with debris?
Explain:
Are appropriate educational materials being developed and distributed ❑ Yes ❑ No DNA [ IE
to prevent future similar occurrences?
Comments:
Form CS-SSO Page 10

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 ❑NA NE
If Yes, explain:
If the problem could not be immediately repaired,what actions ❑ Yes ❑ No ❑NA eir NE
were taken to lessen the impact of the SSO?
Comments:
Form CS-SSO Page 11

Pipe Failure (Break)
Pipe size(inches)
What is the pipe material
What is the approximate age of the line/pipe(years old)
Is this a gravity line? ❑ Yes ❑ No ❑NA [41 NE
Is this a force main line? ❑ Yes ❑ No DNA NE
Is the line a"High Priority"line? ❑ Yes ❑ No DNA I] NE
Last inspection date and findings
If a force main then,
Was the break on the force main vertical? ❑ Yes ❑ No DNA rtl NE
Was the break on the force main horizontal? ❑ Yes ❑ No ❑NA ® NE
Was the leak at the joint due to gasket failure? ❑ Yes ❑ No DNA (7E] NE
Was the leak at the joint due to split bell? ❑ Yes ❑ No ❑NA LLV NE
When was the last inspection or test of the nearest air-release valve to determine if operable?
When was the last maintenance of the air release performed?
If gravity sewer then,
Does the line receive flow from a force main immediately upstream ❑ Yes ❑ No ❑NA NE
of the failed section of pipe?
If yes,what measures are taken to control the hydrogen sulfide production?
When was the line last inspected or videoed?
If line collapsed,what is the condition of the line up and down stream of the failure?
What type of repair was made?
If temporary,when is the permanent repair planned?
Have there been other failures of this line in the past five years? ❑ Yes ❑ No ❑NA dE NE
If so,then describe
Form CS-SSO Page 12

T
System Visitation
ORC ] Yes
Backup 0 Yes
Name: rpt3or,74S 5,- i✓4 e/
Certification Number:/a0 y f
Date visited:b►r.0‘1_atiaf/ ,r
Time visited:4,•,?c,�,id �iSlG�'iv' C✓i 6Z1/ SO �l (� � SSO 57'ilopiwz
How was the SSO remediated (i./e. Stopped and cleane up)?
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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:��p 7 S J it/ / Date: C' ' O / " O� I
Signature: Title: P14,96)G 56-K1.11 G,3 �y/a; re)K
Telephone Number:
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five
business 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).
Form CS-SSO Page 13