WQCSD0030_Report_20220328

State of North Carolina
RECEIVED Department of Environment and Natural Resources
22�2� Division of Water Resources
5Collection System Sanitary Sewer Overflow Reporting Form
Division of Water Resources NCDEQ/DWR/NPDES Form CS-SSO
PART!:
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. ( ) (C.5 1) t'a 3 r' (WOCS#if active,otherwise use WQCSD#) _„ II i
Facility: GS Incident#: a0�f� 6a137 Owner. /.fin 4PLi od.JarcJ
Region: 'Rat.(e.i 5 h city: j.J bbl(b n A County: Ikle f4a It 0
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.): Fit ti 23't//U f- .tiJ P)n
Manhole#:
Latitude(degrees/minute/second): Longitude(degrees/minute/second):
Incident Started Dt: b 3//2-/aD2LTime: Dq.`C Opp rw Incident End Dt: =` % )%-!- Time: D r,
tmm-dd-yyyy) (hh:mm)AM/PM (mm-dd-yyyy) (hh:mm)AM/PM
Estimated volume of the SSO: '01) gallons Estimated Duration(round to nearest hour): hour(s)
Describe how the volume was determined: t/ju sL/
6
Weather conditions during the SSO event: I4e.Vy Za,
Did the SSO reach surface waters? El Yes �No ❑ Unknown
Volume reaching surface waters: gallons Surface water name:
Did the SSO result in a fish kill? ❑Yes ErNo ❑Unknown
If Yes,what is the estimated number of fish killed?
SPECIFIC cause(s)of the SSO:
❑Severe Natural Conditions ❑ Grease ❑Roots Dlnflow&Infiltration
['Pump Station Equipment Failure ❑Power Outage ❑Vandalism ❑ Debris in line ❑Pipe Failure(Break)
Dottier(Please explain in Part II)24-hour verbal notification (name of person contacted): / cSC) �^4 ( CC&A
❑DWR [emergency Management Date(mm-dd-yyy): 0 3J)Z/ c lTmme:(hh:mm AM/PM): o ./04r''"--
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 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
Form CS-SSO Page 1

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1

•
Are you under an SOC(Special Order by Consent)or do you have a schedule ❑Yes 1;4 No DNA ❑ NE
in any permit that addresses WI?
Explain if Yes:
What corrective actions have been taken to reduce or eitilinate I&I related overflows this spi location
within the last year? r1 J 5_� rril vi 7 1 �. � �G7
C u �T i! G,7 IA� j'Y� ('G- '7'�'2 S t�d.v
Has there been any flow studies to determine UI problems in the ©Yes ❑ No DNA ❑ NE
collection system at the SSO location?
If Yes,when was the study completed and what actions did it recommend? rt°4,
Has the line been smoke tested or videoed within the past year? ❑ Yes D No DNA ❑ NE
tf Yes,when and what actions are necessary and the status of such actions:
Are there UI related projects in your Capital Improvement Plan? VI Yes ❑ No DNA ❑ NE
tf Yes,explain: rep)/c t- 961 f r 0 G C
Have there been any grant or loan applications for IR reduction projects? ]Yes ❑ No DNA ❑ NE
If Yes,explain: C A.P 4-
Do you suspect any major sources of inflow or cross connections 21 Yes ❑ No DNA ❑ NE
with storm sewers?
If Yes,explain: (/v a+ c'j e(-try Fa rr(n ()Se c 7,1- �- eie -
Have all lines contacting surface waters in the SSO location and upstream ❑Yes ❑ No DNA ❑ NE
been inspected recently?
If Yes,explain:
What other corrective actions are planned to prevent future VI related SSOs at this location?
Comments: 4.plir cs 4 t 1-1 y ) 4 z/t S
Form CS-SSO Page 6

-What kind of notification/alarm systems are present?
Auto-dialer/telemetry(one-way communication) ®Yes
Audible ®Yes
V ®Yes
SCADA(two-way communication) ❑Yes
Eby Contact Signage ❑Yes
Other ❑Yes
If Yes,explain:
Describe the equipment that failed: /i//i
What kind of situations trigger an alarm condition at this station(Le.pump failure,power failure,high water,etc.)?
Were notification/alarm systems operable? (EYes ❑ No DNA ❑ NE
In no,explain:
If a pump faded,when was the last maintenance and%or inspection performed?
What specifically was checked/maintained?
If a valve failed,when was it last,exercised?
Were ail pumps set to alternate? 0 Yes 0 No DNA 0 NE
Did any pump show above normal run times prior to and during the SSO event? 0 Yes ❑ No DNA ❑ NE
Were adequate spare parts on hand to fax the equipment ®Yes ❑ No DNA ❑ NE
Was a spare or portable pump immediately available? ,®Yes ❑ No DNA ❑ 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

•
ORC I Yes ❑ No
Backup 0 Yes 0 No
Name: C /l�fbN � 0
Certification Number
Date visited: D�J/z J 23 2 2-
Tim 35 4�,
e visited: .3S b/ v e l t
y
How was the SSO remediated(i./e.Stopped and dewed up)?
eon's/ex/ ,,iL1 je .tre
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: e pate: 0 l(, v� 7��-
l /
Signature: Title: nee"
Telephone Number f2.12 -2 v — /7S ilk
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