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Home My WebLink AboutWQCS00299_Report_20211101 State of North Carolina Department of Environment and Natural Resources Division of Water Resources Collection System Sanitary Sewer Overflow Reporting Form Form CS-SSO Form CS-SSO Page 1 PART I: This form shall be submitted to the appropriate DWR Regional Office within five business days of the first knowledge of the sanitary sewer overflow (SSO). Permit Number: ___________________________ (WQCS# if active, otherwise use WQCSD#) Facility: ______________________________ Region: _____________________________ City: ________________ County: ___________________ Source of SSO (check applicable): Sanitary Sewer 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 Westall & Bragg Street, etc.): _________________________________________________________ Manhole #: ___________________________________ Latitude (degrees/minute/second): __________________ Longitude (degrees/minute/second): __________________ Incident Started Dt: _____________ Time: __________ Incident End Dt: _____________ Time: _________________ (mm-dd-yyyy) (hh:mm) AM/PM (mm-dd-yyyy) (hh:mm) AM/PM Estimated volume of the SSO: _________________ gallons Estimated Duration (round to nearest hour): ____hour(s) Describe how the volume was determined: ________________________________________________________________ Weather conditions during the SSO event: ________________________________________________________________ Did the SSO reach surface waters? Yes No Unknown Volume reaching surface waters: __________________gallons Surface water name: _______________________ Did the SSO result in a fish kill? Yes 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 Emergency Management Date (mm-dd-yyy): __________ Time: (hh:mm AM/PM): ____________ Per G.S. 143-215.1C(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 r elease 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 to 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 WQCS00299 Elm City Collection System I ncident # 202102060 : _____________ ____ O wner: _Town of Elm City___________________ Raleigh Elm City Wilson X Parker Street 10/18/2021 1400 10/18/2021 1515 50 1 top and side of manhole was wet - ORC did not see any flow clear X 50 Cattail Swamp X X Pump was not pumping X 10/18/21 1225 Form CS-SSO Page 2 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 7 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) Audible Visual SCADA (two-way communication) Emergency Contact Signage Other 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? 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 NE Did any pump show above normal run times prior to and during the SSO event? Yes No NA NE Were adequate spare parts on hand to fix the equipment NA NE Was a spare or portable pump immediately available? Yes No NA 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? ___________________________________________ X NA Yes No Yes No NA NE X 10/13/2021 normal working operations X X X FLOAT STUCK Comments: _____There are not any spare pumps and the system is operating on a portable pump____ ____________________________________________________________________________________________________ Yes Yes Yes Yes Yes Yes X If Yes, explain: ______________________________________________________________________________ Describe the equipment that failed: ___Pump failed- __Pulled suction hose and cleaned-was full of rags, etc._from the collection system _____________ Form CS-SSO Page 13 System Visitation ORC Yes No Backup Yes No Name: __________________________ Certification Number: __________________________ Date visited: __________________________ Time visited: __________________________ How was the SSO remediated (i./e. Stopped and cleaned up)? __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ As a representative for the responsible party, I certify that the information contained in this report is true and acc urate to the best of my knowledge. Person submitting claim: __________________________ Date: __________________________ Signature: ______________________________________________ Title: ___________________________________ Telephone Number: Any additional information desired to be submitted shoul d 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). X William Lamm 11693 10/18/2021 1400 lime was applied Rebecca Manning 10/21/2021 Compliance Coordinator