WQCS00217_DV-2022-0001_20220216

ROY COOPER
Governor
EUZABETH S. BISER
Secretary
S. DANIEL SMITH
Director
Certified Mail # 7020 3160 0000 4109 5022
Return Receipt Requested
Matthew Klein
Carolina Trace Utilities Inc.
PO Box 240908
Charlotte, NC 28224-0908
NORTH CAROLINA
Environmental Quality
February 16, 2022
SUBJECT: Notice of Violation and Assessment of Civil Penalty
for Violations of North Carolina General Statute (G.S.) 143-215.1(a)(1)
and Collection System Permit No. WQCS00217
Carolina Trace Utilities Inc.
Carolina Trace Collection System
Case No. DV-2022-0001
Lee County
Dear Mr. Klein:
This letter transmits a Notice of Violation and assessment of civil penalty in the amount of $786.57 ($750.00 civil penalty +
$36.57 enforcement costs) against Carolina Trace Utilities Inc.
This assessment is based upon the following facts: a review has been conducted of the Sanitary Sewer Overflow (SSO)
5-Day Report submitted by Carolina Trace Utilities Inc. This review has shown the subject facility to be in violation of the
requirements found in Collection System Permit No. WQCS00217 and G.S. 143-215.1(a)(1). The violations) that occurred
are summarized in Attachment A to this letter.
Based upon the above facts, I conclude as a matter of law that Carolina Trace Utilities Inc. violated the terms, conditions or
requirements of Collection System Permit No. WQCS00217 and G.S. 143-215.1(a)(1) in the manner and extent shown in
Attachment A. In accordance with the maximums established by G.S. 143-215.6A(a)(2), a civil penalty may be assessed
against any person who violates the terms, conditions or requirements of a permit required by G.S. 143-215.1(a).
,Iltqs)
North Carolina Department of Environmental Quality DlvhlonofWater Resources
Raklph Regional Office 13E00 Darren Drive i Raklgh North Carolina 27609
919.7914200

Based upon the above findings of fact and conclusions of law, and in accordance with authority provided by the
Secretary of the Department of Environmental Quality and the Director of the Division of Water Resources, I, Scott
Vinson, Regional Supervisor, Raleigh Regional Office hereby make the following civil penalty assessment against
Carolina Trace Utilities Inc.:
$750.00 For 1 of the 1 violations of Collection System Permit No. WQCS00217 and G.S. 143-215.1(a)(1) for
Sanitary Sewer Overflow(s) resulting in a discharge without a valid permit.
$750.00 TOTAL CIVIL PENALTY
$36.57 Enforcement Costs
$786.57 TOTAL AMOUNT DUE
Pursuant to G.S. 143-215.6A(c), in determining the amount of the penalty I have taken into account the Findings of Fact and
Conclusions of Law and the factors set forth at G.S. 143B-282.1(b), which are:
(1) The degree and extent of harm to the natural resources of the State, to the public health, or to private property
resulting from the violation;
(2) The duration and gravity of the violation;
(3) The effect on ground or surface water quantity or quality or on air quality;
(4) The cost of rectifying the damage;
(5) The amount of money saved by noncompliance;
(6) Whether the violation was committed willfully or intentionally;
(7) The prior record of the violator in complying or failing to comply with programs over which the Environmental
Management Commission has regulatory authority; and
(8) The cost to the State of the enforcement procedures.
Within thirty (30) days of receipt of this notice, you must do one of the following:
(1) Submit payment of the penalty, OR
(2) Submit a written request for remission, OR
(3) Submit a written request for an administrative hearing
Option 1: Submit payment of the penalty:
Payment should be made directly to the order of the Department of Environmental Quality (do not include waiver
form). Payment of the penalty will not foreclose further enforcement action for any continuing or new violation(s).
Please submit payment to the attention of:
Attn: PERCS Branch
Division of Water Resources
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

Option 2: Submit a written request for remission or mitigation including a detailed justification for such
request:
Please be aware that a request for remission is limited to consideration of the five factors listed below as they may
relate to the reasonableness of the amount of the civil penalty assessed. Requesting remission is not the proper
procedure for contesting whether the violation(s) occurred or the accuracy of any of the factual statements contained in
the civil penalty assessment document. Because a remission request forecloses the option of an administrative hearing,
such a request must be accompanied by a waiver of your right to an administrative hearing and a stipulation and
agreement that no factual or legal issues are in dispute. Please prepare a detailed statement that establishes why you
believe the civil penalty should be remitted, and submit it to the Division of Water Resources at the address listed below.
In determining whether a remission request will be approved, the following factors shall be considered:
(1) whether one or more of the civil penalty assessment factors in NCGS 143B-282.1(b) was wrongfully
applied to the detriment of the petitioner;
(2) whether the violator promptly abated continuing environmental damage resulting from the violation;
(3) whether the violation was inadvertent or a result of an accident;
(4) whether the violator had been assessed civil penalties for any previous violations; or
(5) whether payment of the civil penalty will prevent payment for the remaining necessary remedial actions.
Please note that all evidence presented in support of your request for remission must be submitted in writing. The
Director of the Division of Water Resources will review your evidence and inform you of his decision in the matter of
your remission request. The response will provide details regarding the case status, directions for payment, and
provision for further appeal of the penalty to the Environmental Management Commission's Committee on Civil Penalty
Remissions (Committee). Please be advised that the Committee cannot consider information that was not part of the
original remission request considered by the Director. Therefore, it is very important that you prepare a complete and
thorough statement in support of your request for remission.
In order to request remission, you must complete and submit the enclosed "Request for Remission of Civil Penalties,
Waiver of Right to an Administrative Hearing, and Stipulation of Facts" form within thirty (30) days of receipt of this
notice. The Division of Water Resources also requests that you complete and submit the enclosed "Justification for
Remission Request."
Both forms should be submitted to the following address:
Attn: PERCS Branch
Division of Water Resources
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
AND
Scott Vinson, Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
1628 Mail Service Center, Raleigh
Raleigh, NC 27699-1628

Option 3: File a petition for an administrative hearing with the Office of Administrative Hearings:
If you wish to contest any statement in the attached assessment document, you must file a petition for an administrative
hearing. You may obtain the petition form from the Office of Administrative Hearings. You must file the petition with
the Office of Administrative Hearings within thirty (30) days of receipt of this notice. A petition is considered filed
when it is received in the Office of Administrative Hearings during normal office hours. The Office of Administrative
Hearings accepts filings Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m., except for official state
holidays. The petition may be filed by facsimile (fax) or electronic mail by an attached file (with restrictions) - provided
the signed original, one (1) copy and a filing fee (if a filing fee is required by NCGS §150B-23.2) is received in the
Office of Administrative Hearings within seven (7) business days following the faxed or electronic transmission. You
should contact the Office of Administrative Hearings with all questions regarding the filing fee and/or the details of the
filing process.
The mailing address and telephone and fax numbers for the Office of Administrative Hearings are as follows:
6714 Mail Service Center
Raleigh, NC 27699 6714
Tel: [phone]
Fax: [phone]
One (1) copy of the petition must also be served on DEQ as follows:
Mr. William F. Lane, General Counsel
Department of Environmental Quality
1601 Mail Service Center
Raleigh, North Carolina 27699-1601
Please indicate the case number (as found on page one of this letter) on the petition.
Failure to exercise one of the options above within thirty (30) days of receipt of this letter, as evidenced by an internal
date/time received stamp (not a postmark), will result in this matter being referred to the Attorney General's Office for
collection of the penalty through a civil action. Please be advised that additional penalties may be assessed for violations
that occur after the review period of this assessment.
If you have any questions, please contact Mitchell Hayes with the Division of Water Resources staff of the Raleigh
Regional Office at [phone] or via email at mitch.hayesqtncdenr.gov.
Sincerely,
Scott Vinson, Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
ATTACHMENTS
Cc: WQS Raleigh Regional Office - Enforcement File
Laserfiche

JUSTIFICATION FOR REMISSION REOUEST
Case Number: DV-2022-0001
Assessed Party: Carolina Trace Utilities Inc.
Permit No.: WQCS00217
County: Lee
Amount Assessed: $786.57
Please use this form when requesting remission of this civil penalty. You must also complete the "Request For Remission,
Waiver of Right to an Administrative Hearing, and Stipulation of Facts" form to request remission of this civil penalty.
You should attach any documents that you believe support your request and are necessary for the Director to consider in
evaluating your request for remission. Please be aware that a request for remission is limited to consideration of the five
factors listed below as they may relate to the reasonableness of the amount of the civil penalty assessed. Requesting
remission is not the proper procedure for contesting whether the violation(s) occurred or the accuracy of any of the factual
statements contained in the civil penalty assessment document. Pursuant to N.C.G.S. § 143B-282.1(c), remission of a civil
penalty may be granted only when one or more of the following five factors apply. Please check each factor that you
believe applies to your case and provide a detailed explanation, including copies of supporting documents, as to why the
factor applies (attach additional pages as needed).
(a) one or more of the civil penalty assessment factors in N.C.G.S. 143B-282.1(b) were wrongfully applied to the
detriment of the petitioner (the assessment factors are listed in the civil penalty assessment document);
(b) the violator promptly abated continuing environmental damage resulting from the violation (i.e., explain the
steps that you took to correct the violation and prevent future occurrences);
(c) the violation was inadvertent or a result of an accident (i.e., explain why the violation was unavoidable or
something you could not prevent or prepare for);
(d) the violator had not been assessed civil penalties for any previous violations;
(e) payment of the civil penalty will prevent payment for the remaining necessary remedial actions (i. e., explain
how payment of the civil penalty will prevent you from performing the activities necessary to achieve
compliance).
EXPLANATION:

STATE OF NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
COUNTY OF LEE
IN THE MATTER OF ASSESSMENT
OF CIVIL PENALTIES AGAINST
Carolina Trace Utilities Inc.
Carolina Trace Collection System
PERMIT NO. WQCS00217
) WAIVER OF RIGHT TO AN
) ADMINISTRATIVE HEARING AND
) STIPULATION OF FACTS
)
)
)
) CASE NO. DV-2022-0001
Having been assessed civil penalties totaling $786.57 for violation(s) as set forth in the assessment document of the Division
of Water Resources dated February 16, 2022, the undersigned, desiring to seek remission of the civil penalty, does hereby
waive the right to an administrative hearing in the above -stated matter and does stipulate that the facts are as alleged in the
assessment document. The undersigned further understands that all evidence presented in support of remission of this civil
penalty must be submitted to the Director of the Division of Water Resources within thirty (30) days of receipt of the notice
of assessment. No new evidence in support of a remission request will be allowed after (30) days from the receipt of the
notice of assessment.
This the day of , 20
SIGNATURE
ADDRESS
TELEPHONE

ATTACHMENT A
Carolina Trace Utilities Inc
CASE NUMBER: DV-2022-0001
PERMIT NO: WQCS00217
FACILITY: Carolina Trace Collection System
Other Violations
INCIDENT VIOLATION
NUMBER DATE VIOLATION TYPE
REGION: Raleigh
COUNTY: Lee
VIOLATION DESCRIPTION
TOTAL VOLUME PENALTY
(GALLONS) AMOUNT
202101929 8/4/2021 CSO/SSO(Sewer Overflow) Discharge without valid permit 12,000 $750.00

DIVISION OF WATER RESOURCES - CIVIL PENALTY ASSESSMENT
Violator: Carolina Trace Utilities Inc.
Facility Name: Carolina Trace Collection System
Permit Number: WOCS00217
County: Lee
Case Number: DV-2022-0001
ASSESSMENT FACTORS
1) The degree and extent of harm to the natural resources of the State, to the public health, or to private
property resulting from the violation;
A total of 12,000 gallons overflowed from a manhole due to roots in the line. All 12,000 flowed into Lake Trace; Upper
Little River, Class C waters in the Cape Fear River Basin. Increased nutrients and pathogens to surface waters.
2) The duration and gravity of the violation;
The SSO started 08.04.2021 at 6:40 am and ended the same day at 11:40 am.
3) The effect on ground or surface water quantity or quality or on air quality; Increased nutrients and pathogens to surface waters C Cc. i- wog ` tt^-`- ai-
4) The cost of rectifying the damage;
The costs of rectifying the damage is not given.
5) The amount of money saved by noncompliance;
It is believed that no money was saved by the noncompliance.
6) Whether the violation was committed willfully or intentionally;
It does not appear that the violation was committed willfully or intentionally.
7) The prior record of the violator in complying or failing to comply with programs over which the
Environmental Management Commission has regulatory authority;
There have been zero enforcement cases against the violator.
8) The cost to the State of the enforcement procedures.
$36.57
Date
Scott Vinson, Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ

NCDENR
A7A
C
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Pat McCrory Thomas A. Reeder John E. Skvarla, Ill
Governor Acting Director Secretary
July 11, 2013
Mr. Martin Lashua, Regional Director
Carolina Trace Utilities Inc.
PO Box 240908
Charlotte, NC 28224
Subject: Permit No. WQCS00217
Carolina Trace Utilities Inc
Carolina Trace Collection System
Lee County
Dear Mr. Lashua:
In accordance with your application received June 6th, 2013, we are forwarding herewith Permit
No. WQCS00217, dated July 11, 2013, to the Carolina Trace Utilities Inc for the operation and
maintenance of the subject wastewater collection system.
This permit shall be effective from December 1st, 2013 until November 30th, 2021 and shall be
subject to the conditions and limitations specified herein. It is your responsibility to thoroughly
review this permit. Please pay particular attention to the monitoring and reporting requirements
in this permit and any compliance schedules shown in bold.
For purposes of permitting, the collection system is considered to be any existing or newly
installed system extension up to the wastewater treatment facility property or point of connection
with a separately owned sewer system. The collection system is considered all gravity lines,
pump stations, force mains, low pressure sewer systems, STEP systems, vacuum systems, etc.
and associated piping, valves and appurtenances that help to collect, manage and transport
wastewater to a wastewater treatment plant under the Permittee's ownership or maintained and
operated by the Permittee through a perpetual legal agreement. Satellite systems are systems
tributary to the Permittee's collection system but those collection systems are not owned or
maintained by the Permittee. The system description provided on Page 1 of this permit is meant
to provide a general idea about the size of the system and may not be all inclusive of the
collection system at the time of permit issuance or afterward.
A release of wastewater from the wastewater collection system is referred to herein as a Sanitary
Sewer Overflow (SSO). The evaluation of enforcement options after an SSO will be determined
considering the criteria listed in condition I(3)(a) and I(3)(b) of the permit and all other relevant
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone]
Internet www.ncwaterouaiity.oro
An Equal Opportunity I Affirmative Action Employer
NorthCarolina
atura!!i

Carolina Trace Collection s ( .i
July 1 1, 2013
Page 2 of 3
information available or requested of the Permittee. Compliance with all conditions of the
permit as well as all statutes and regulations pertaining to the collection system must be
maintained or appropriate enforcement actions may be taken as noted in Condition VI(2).
A reportable SSO is an SSO greater than 1,000 gallons to the ground or an SSO of any amount
that reaches surface water (including through ditches, storm drains, etc.) Below is the procedure
to use for reporting SSOs to the Division:
1. Report by telephone to a Division of Water Quality (DWQ) staff member (not email,
facsimile, or voicemail) at your regional DWQ office during regular business hours
(Monday to Friday, 8AM to 5PM) as soon as possible, but in no case more than 24 hours
after the SSO is known or discovered. To report outside of regular business hours, call
[phone].
2. Follow up the verbal report by sending a completed written report on the most current
Division approved form within five days.
To provide a uniform method for all systems covered under this permit and to provide useful and
consistent information pertaining to SSOs, please utilize form CS-SSO consisting of two parts.
Part I serves to provide to the Division the required information that has always been necessary.
Part II serves as an area to provide a justification for the spill, as optional under Condition I(3) of
your permit. Form CS-SSO can be downloaded from the SSO Reporting area at
http:l/portal.ncdenr.org/web/wq/swp/ps/csissoreport.
An NOV, civil penalty, and/or a moratorium on the addition of waste to the system may be
issued if adequate justification for an SSO is NOT submitted to the regional office. In order to
submit a claim for justification of an SSO, you must use Form CS-SSO with additional
documentation as necessary. DWQ staff will review the justification claim and determine if
enforcement action is appropriate. Please be advised that the information needed to justify a spill
is very comprehensive. Begin using this form immediately to report SSOs from the collection
system. Continue to use our old form for reporting bypasses at the wastewater treatment plant
until further notice. The time frame for submittal of both Part I and Part II, if pertinent, is five
days.
Failure to abide by the conditions in this permit may subject the Permittee to enforcement action.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the
right to request an adjudicatory hearing upon written request within thirty days following the
receipt of this permit. This request must be in the foram of a written petition, conforming to
Chapter 150B of the North Carolina General Statutes, and filed with the Office of Administrative
Hearings, 6714 Mail Service Center, Raleigh, NC 27699-6714. Unless such demands are made,
this permit shall be final and binding.

ROY COOPER
°own er
EUZABETH S. BISER
Seamy
S. DANIEL SMITH
Director
Certified Mail # 7020 3160 0000 2219 3051
Matthew Klein
Carolina Trace Utilities Inc.
PO Box 240908
Charlotte, NC 28224-0908
NORTH CAROLINA
Ihrbak! Quality
October 05, 2021
SUBJECT: NOTICE OF VIOLATION & INTENT TO ISSUE CIVIL PENALTY
Traddng No.: NOV-2021-DV-0418
Sanitary Sewer Overflows - August 2021
Collection System Permit No. WQCS00217
Carolina Trace Collection System
Lee County
Dear Mr. Klein:
A review has been conducted of the self -reported Sanitary Sewer Overflows (SSO's) 5-Day Report/s submitted by
Carolina Trace Utilities Inc. The Division's Raleigh Regional Office concludes that the Carolina Trace Utilities Inc.
violated Permit Condition I (2) of Permit No. WQCS00217 by falling to effectively manage, maintain, and operate
their collection system so that there is no SSO (Sanitary Sewer Overflow) to the land or surface waters and the
SSO constituted making an outlet to waters of the State for purposes of G.S. 143-215.1(a)(1), for which a permit
is required by G.S. 143-215.1.
The Raleigh Regional Office is providing the Carolina Trace Utilities Inc. an opportunity to provide evidence and
justification as to why the Carolina Trace Utilities Inc. should not be assessed a civil penalty for the violation(s) that
are summarized below:
Incident Start Duration
Number Date (Mins) Location
Cause
Total Vol
Total Surface
Vol Water
(Gals) (Gals) DWR Action
202101929 13/4/2021 1,020 Manhole behind 5055 Roots 12,000 12,000 Notice of Violation
Blue Bird Notice of Intent
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This Notice of Violation / Notice of Intent to Enforce (NOV/NOI) is being issued for the noted violation. Pursuant
to G.S.143-215.6A, a civil penalty of not more than twenty-five thousand dollars ($25,000.00) may be assessed
against any person who violates or fails to act in accordance with the terms, conditions, or requirements of any
permit issued pursuant to G.S. 143-215.1.
This office requests that you respond to this Notice, in writing, within 10 business days of its
receipt In your response, you should address the causes of non-compliance, remedial actions, and all other
actions taken to prevent the recurrence of similar situations. The response to this correspondence will be
considered in this process. Enforcement decisions will also be based on volume spilled, volume reaching surface
waters, duration and gravity, impacts to public health, fish kills or recreational area closures. Other factors
considered in determining the amount of the dvii penalty are the violator's history of non-compliance, the cost of
rectifying the damage, whether the spiii was intentional and whether money was saved by non-compliance.
If you have any questions, please do not hesitate to contact Mitchell Hayes with the Water Quality Section in
the Raleigh Regional Office at 919-791-4200 or via email at [e-mail].
Sincerely,
Scott Vinson, Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
Cc: Raleigh Regional Office - WQS File
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ROY COOPER
Ceronlor
EUZABETH S. BISER
S. DANIEL SMITH
Director
Certified Nall # 7020 3160 0000 2219 3051
Matthew Klein
Carolina Trace Utilities Inc.
PO Box 240908
Charlotte, NC 28224-0908
NORTH CAROUNA
Earfravossetat Quality
October 05, 2021
SUBJECT: NOTICE OF VIOLATION & INTENT TO ISSUE CIVIL PENALTY
Traddng No.: NOV-2021-DV-0418
Sanitary Sewer Overflows - August 2021
Collection System Permit No. WQCS00217
Carolina Trace Collection System
Lee County
Dear Mr. Klein:
MAILED
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A review has been conducted of the self -reported Sanitary Sewer Overflows (SSO's) 5-Day Report's submitted by
Carolina Trace Utilities Inc. The Division's Raleigh Regional Office concludes that the Carolina Trace Utilities Inc.
violated Permit Condition I (2) of Permit No. WQCS00217 by failing to effectively manage, maintain, and operate
their collection system so that there is no SSO (Sanitary Sewer Overflow) to the land or surface waters and the
SSO constituted making an outlet to waters of the State for purposes of G.S. 143-215.1(a)(1), for which a permit
is required by G.S. 143-215.1.
The Raleigh Regional Office is providing the Carolina Trace Utilities Inc. an opportunity to provide evidence and
justification as to why the Carolina Trace Utilities Inc. should not be assessed a civil penalty for the violation(s) that
are summarized below:
Incident Start Duration
Number Doty (Mina) Location
Cause
Total Vol
Total Surface
Vol water
(Gals) (Gals) DWR Action
202101929 8/4/2021 1,020 Manhole behind 5055 Roots 12,000 12,000 Notice of Violation
Blue Bird Notice of Intent
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■ Print your name and address on the reverse
so that we can retu n the card to you.
• Attach this card to the back of the mallptsce,
or on the front If apace pennlle.
i. Artists Addressed to:
MATTHEW KLEIN
CAROUNA TRACE UTILITIES, INC.
PO BOX 240908
CHARLOTTE, NC 28224-0908
Nov 207.1-DV-0418 / NOV-INTFNr TO ASSESS / 20211011
CAROUNA TRACE COU rcr SYS / WQCS00217/ LEE COUNTY
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CAROUNA TRACE COLLECT' SYS / WQCS00217/ LEE COUNTY
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WATER QUALITY REGIONAL OPERATIONS
SECTION
NC DEQ- RALEIGH REGIONAL OFFICE
3800 BARRETT DRIVE
RALEIGH, NC 27609
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State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Division of Water Resources
Collection System Sanitary Sewer Overflow Reporting Form
Form CS-SSO
PART I:
This form shall be submitted to the appropriate DWQ Regional Office within five business days of the first knowledge of the
sanitary sewer overflow (SSO).
Permit Number: WQCS00217 (WQCS# if active, otherwise use WQCSD#)
Facility: Carolina Trace Collection System Incident #: 202101929
Owner: Carolina Trace Utilities Inc
City: Sanford
County: Lee Region: Raleigh
Source of SSO (check applicable): [ZI 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 behind 5055 Blue Bird
Manhole #: MALLARD COVE #31
Latitude (Decimal Degrees): Longitude (Decimal Degrees):
Incident Started Dt: 08/04/2021 Time: 6:40 Incident End Dt: 08/04/2021 Time: 11:40 pm
(mm-dd-yyyy) (hh:mm AM/PM) (mm-dd-yyyy (hh:mm AM/PM)
Estimated Volume of the SSO: 12,000 gallons Estimated Duration (Round to nearest hour): 5:0 hours
Describe how the volume was determined: DWR SSO Flow Est. Guidance
Weather conditions during the SSO event: Normal
Did SSO reach surface waters? [r71 Yes ❑ No ❑ Unknown
Surface water name: Upper Little River
Volume reaching surface waters (gals): 12000
Did the SSO result in a fish kill? ❑ Yes El No ❑ Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
[l Roots
24 hour verbal notification (name of person contacted ): Jerry Belcher
❑ DWR 0 Emergency Mgmt Date (mm-dd-yyy): 08/04/2021 _ Time (hh:mm AM/PM): 06:40:00 pm
If an SSO is ongoing, please notify the appropriate 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 or more of untreated wastewater to surface waters
shall issue a press release within 24-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 reference statute for further detail.
The Director, Division of Water Resources, may take enforcement action for SSOs that are required to be reported to
Division unless it is demonstrated that:
1) the discharge was cause by sever natural conditions and there were no feasible alternative 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
WHETHER OR NOT PART III IS COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM
CS-SSO Form
Page: 1

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
Roots
Do you have an active root control program on the line 1 area in question? ❑ Yes ❑ No ❑ NA ❑ 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:
System Visitation
ORC
Backup
Name:
Cert#
Date visited:
Time visited:
0 Yes
0 Yes
CS-SSO Form Page: 2

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 accurate to the
best of my knowledge.
Person submitting claim: Date:
Signature: Title:
Telephone Number:
Any addition information desired to be submitted should be sent to the appropriate Division Regional Office within five days of I
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of th
form is completed, if used).
CS-SSO Form Page: 3