WQCS00110_BIMS Report_20220316

Region:
State of North Carolina
Department of Ennironmental QuaW
Dhision of Water Resources
`Division of Water Resources Collection System Sanitary Smc r Overflow Reporting Form
Form CS-SSO
PART 1:
This form shall be submitted to the appropriate DW R Regional Office within five business days of the first knowledge of the
sanitary sewer overflow (SSO).
Permit Number. VU UC_S 00110 (WQCS# if active, otherwise use WOCSD#) _
Facility: % ,,,j C,E 6' y1;r0 j Incident #: �.2022A0`10S Owner -
County: Jw,r.,ls iu.-J
City: C&IMb .✓
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 Wesfall & Bragg Street, etc_): LiNf SPyi►r��� /f 30 &42e -?/% Jr & �exAg^j S4--
Manhole #: _X73 2-
Latitude (degrees/minute/second): 3r G .t'37'7`--
Incident Started Dt: 3 -J S'- 2 2 Time: 70,3,A"
Longitude (degrees/minute/second): " 7O. �G,�.�7
Incident End Dt: 3 /S-,2 2 Time: 73 0?A1
(mm-dd-yyyy) (hh:mm) AMIPM (mm-dd-yyyy) (trh:mm) AM/PM /
Estimated volume of the SSO: .210 gallons Estimated Duration (round to nearest hour):4L- hours)
Describe how the volume was determined: •X &�. saltic✓u,�•c 70 �.f' 3 �� / er
Weather conditions during the SSO event el / <
Did the SSO reach surface waters? 0 Yes ❑ No ❑ Unknown
Volume reaching surface waters: .S`Q gallons Surface water name: `%tin 401)
Did the SSO result in a fish 1617 ❑ Yes ErNo ❑ 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 Iloe ❑Pipe Failure (Break)
❑Other (Please explain in Part 11)
244hour verbal notification (name of person contacted): CIII& S
❑DWR 0Emergency Management Date (mm-dd-yyy):. �� JS-?�2Z Time: (hh mm AMfPM): Off
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 1,0W 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 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 11 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

r0�
Eta, you have art active roat control program on the, Nne t area tin; stwes#? ,[ Yes ❑ No ❑NA ❑ NE
Describee.: 44r 441zf /E ,&I-S 6� Awe /A/ W VM42//y R.,�I 400-4
Have cleaning and inspections ever been increased at this location because
of roots?
❑ Yes No ❑ NA ❑ NE
Explain: -Ale r4tk Af Yew
s�
What corrective actions have been accomplished at the SSO location (and sunrounding system if associated with the SSO)?
What carnedive actions are planned at the SSO location to reduce root ? AP/ 4 /0" "b
H
as the ine been smoke tested or videoed within the pest Yeas? ❑ Yes [!�No ❑NA ❑ NE
9 Yes, when?
Form CS-SSO Page 5

Inflow and Irr6ottration
Are you undler an SOC (Special Order by Consent) or do you have a sche€ We ❑ Yes ❑ No [:]NA ❑ NE
iD any pemd IW addresses, l/i?
Explain it Yes:
What corrective actions have been taken to reduce or eliminate I & I related overflows this spill location
within the Bast year?
Has there been any flow studies to determine LA problems in the
collection system at the SSO location?
tI Yes, when was the study completed and what actions did it recommend?
Has the Irre been smoke tested or vKleoed within the past year?
If Yes, when and what actions are necessary and the status of such actions:
Are there III mated pwiec s in your Capital Improvement Plan?
if Yes, explain:
Have there been any grant or ban applications for UI reduction projects?
If Yes, explain:
Do you suspect any rrrajor sources of inflow or cross connections
witty storm sewers?
it Yes, explain:
Have al tines contacting surface waters in the SSO location and upstream
been inspected recentlp
li Yes, explain:
❑ Yes ❑ No ❑NA ❑ NE
❑ Yes ❑ No []NA ❑ NE
❑ Yes ❑ No []NA ❑ NE
❑ Yes ❑ No ❑NA ❑ NE
❑ Yes ❑ No []NA ❑ NE
❑ Yes ❑ No ❑NA ❑ NE
What other corrective actions are planned to prevent future UI related SSOs at this location?
Comments:
Form CS-SSO Page 6

Svstem Visitation
ORC ,Yes ❑ No
Backup PYes ❑ No
Name: '6/i4ae-e
Certification Number: /0W021
Date visited:
Time visited: 8/s;�-110
How was the SSO remediated (i./e. Stopped and cleaned up)?
Ar oyel t Gro041 I-em Ow— a//
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.
f/
Person submitting claim: D,*,Y� � /j �4'e�k Date: �v '—
Signatur .
Title.
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).
/jj� !/1,V�Ol7� /i�
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fe'v '4"ied mc4,k J t.,Ae - rW IeAK htl,46, r//&y- !✓wj
ellldl",ce- o1-/ww� 6/-,c�� oDc-NJAY� o1�.ti ss.,vf 0`7"
Form CS-SSO Page 13